Arteriovenous Graft Placement Research Articles

Axillary to Common Iliac Arteriovenous Graft for Hemodialysis Access: Case Report and Review of “Exotic” Axillary-Based Grafts

A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice--once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection--but continues to serve as sufficient access after 15 months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages. The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon's armamentarium for complex vascular access cases.

Abords vasculaires pour hémodialyse

Hemodialysis treatments necessitate three times a week a double access to the blood circulation of the patients, allowing for flow-rates above 350 ml/min. Apart from end-stage renal disease, similar vascular accesses may be necessary for treatment of different chronic diseases, especially in children. Microsurgical creation of a direct arteriovenous fistula results in the enlargement of a superficial vein which becomes routinely easy to puncture. It is the best long-term angio-access. In contrast, the placement of prosthetic arteriovenous grafts frequently results in the development of early stenoses at the venous anastomosis that will lead to acute thrombosis. Central venous catheters placed through the internal jugular vein are very useful in case of urgent need for dialysis, but they are prone to infection and they frequently cause central vein stenosis or thrombosis; such procedure should be avoided therefore, as much as possible. Currently, duplex-ultrasound and interventional radiology play a major role in the creation and maintenance of hemodialysis vascular access.

Squamous cell carcinoma in situ arising at the exit site of a tunneled catheter

Squamous cell carcinoma (SCC) is a well-known complication of immunosuppression associated with organ transplantation. It may arise de novo or from previously existing in situ lesions (Bowen’s disease). Concurrent human papilloma virus infection often has an etiologic role, and SCC may follow an aggressive course in immunosuppressed patients. The authors describe a liver transplant patient in whom end-stage renal disease developed. She underwent tunneled catheter placement followed by arteriovenous graft placement. Subsequently, a large SCC in situ at the exit site of her prior tunneled hemodialysis catheter occurred. The growth was removed surgically without complication. SCC has not been reported previously to arise from a catheter exit site. This entity is common in renal and other transplant populations and may follow an aggressive course. It should be sought out by careful skin evaluation to include areas not routinely exposed to the sun. Squamous cell carcinoma (SCC) is a well-known complication of immunosuppression associated with organ transplantation. It may arise de novo or from previously existing in situ lesions (Bowen’s disease). Concurrent human papilloma virus infection often has an etiologic role, and SCC may follow an aggressive course in immunosuppressed patients. The authors describe a liver transplant patient in whom end-stage renal disease developed. She underwent tunneled catheter placement followed by arteriovenous graft placement. Subsequently, a large SCC in situ at the exit site of her prior tunneled hemodialysis catheter occurred. The growth was removed surgically without complication. SCC has not been reported previously to arise from a catheter exit site. This entity is common in renal and other transplant populations and may follow an aggressive course. It should be sought out by careful skin evaluation to include areas not routinely exposed to the sun.

Squamous cell carcinoma in situ arising at the exit site of a tunneled catheter

Squamous cell carcinoma (SCC) is a well-known complication of immunosuppression associated with organ transplantation. It may arise de novo or from previously existing in situ lesions (Bowen's disease). Concurrent human papilloma virus infection often has an etiologic role, and SCC may follow an aggressive course in immunosuppressed patients. The authors describe a liver transplant patient in whom end-stage renal disease developed. She underwent tunneled catheter placement followed by arteriovenous graft placement. Subsequently, a large SCC in situ at the exit site of her prior tunneled hemodialysis catheter occurred. The growth was removed surgically without complication. SCC has not been reported previously to arise from a catheter exit site. This entity is common in renal and other transplant populations and may follow an aggressive course. It should be sought out by careful skin evaluation to include areas not routinely exposed to the sun.

Strategies for Hemodialysis Access: Where to Start, Where to Go Next

Complications of vascular access are the most common cause of hospitalization for patients with end stage renal disease. Physicians involved in the placement and maintenance of hemodialysis access must have a long-term strategy for sequential placement of autogenous fistulas and synthetic grafts to preserve limited access sites. Although many principles involving hemodialysis access surgery are widely accepted, significant controversies exist regarding optimal access strategies. Autogenous access is generally preferred over prosthetic grafts. The nondominant upper extremity is the preferred site of initial access. Cuffed catheters are discouraged for long-term vascular access unless no other options are present. Recent advances in forearm, upper arm, and femoral venous transpositions have facilitated the performance of increased numbers of autogenous access procedures. Nevertheless, substantial numbers of patients on chronic hemodialysis require prosthetic arteriovenous grafts. Although the Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation has provided general guidelines for access creation, considerable controversy remains regarding the optimal choice of prosthetic graft material and configuration. We present a strategy for the sequential placement of arteriovenous fistulas, venous transpositions, and arteriovenous grafts to guide the surgeon in the management of these often challenging patients.

Epidemiology of vascular access in the Australian hemodialysis population

A number of demographic and comorbid factors have been demonstrated to be associated with the placement of arteriovenous grafts (AVG) and central venous catheters (CVC) as opposed to native arteriovenous fistulas (AVF). However, no data are available regarding these factors in a hemodialysis population where AVF utilization is high. All adult patients on hemodialysis on September 30, 2001 in Australia were included in the study. Vascular access was recorded as AVF, AVG, or CVC. Patients were separated into incident (<150 days since first dialysis) and prevalent cohorts (> or =150 days). Multinomial logistic regression was used to assess factors associated with AVG and CVC use. Of the 4968 patients who were studied, 877(17%) were classed as incident and the remainder prevalent. AVF were present in 61% versus 77%, AVG were present in 11% versus 19%, and CVC were present in 28% versus 4% in the incident and prevalent cohorts, respectively (all P < 0.001). After adjustment for confounding factors, age and female gender were associated with an increased frequency of AVG in both cohorts. In addition, type I diabetes mellitus was associated with increased frequency of AVG use in the incident cohort, whereas body mass index (BMI) > or =30 kg/m2 and peripheral vascular and cerebrovascular disease were significant in the prevalent group. For CVC, female gender, type I and II diabetes mellitus and late referral were associated with increased frequency in the incident cohort, while females, cigarette smoking, and peripheral vascular disease were predictive in the prevalent group. Significant variations in access type were also seen depending on geographic location. Certain patient characteristics such as age and female gender, but not type II diabetes mellitus, remain significantly associated with AVG and catheter use despite the high prevalence of AVF use in Australia. However, the significant variation in risk by geographic location suggests more attention needs to be paid to physician practice patterns to increase AVF utilization rates.

The use of cryopreserved femoral vein grafts for hemodialysis access in patients at high risk for infection: A word of caution

Background: Several studies have reported success in the use of venous homografts for arteriovenous access and for arterial bypass in infected fields. On the basis of these reports and in an effort to prevent the loss of vascular access to infection, we performed arteriovenous graft placement with cryopreserved femoral vein in patients at high risk for graft infection. This study reviews the results of our experience. Methods: Of approximately 3100 dialysis access operations performed in a single vascular surgery service between October 1999 and July 2001, 20 patients received arteriovenous access grafts with cryopreserved femoral vein. All patients were judged to be at high risk for infection of the access on the basis of the presence of active infection at the time of graft implantation, the location of the graft in the thigh position, or a history of multiple access infections. The grafts were placed in three locations: thigh (n = 14), upper extremity (n = 3), and chest wall (n = 3). Results: No early operative deaths or graft thromboses were seen. There were three late deaths: two from cardiac disease and one from a graft-related complication. Thirteen major graft related complications (65%) occurred in the 20 patients. There were three generalized graft infections (15%) and eight localized graft infections (40%) at dialysis needle access sites in 11 patients. Six of the graft infections were associated with graft rupture and frank hemorrhage, resulting in one patient death from exsanguination. Two grafts (10%) thrombosed, one of which was salvaged after thrombectomy and revision. These complications occurred between 1 and 14 months after implantation. At a mean follow-up period of 13 months (range, 1 to 17 months), only five of the 20 patients (25%) have a functioning cryopreserved femoral vein arteriovenous graft. Conclusion: The use of cryopreserved vein graft for hemodialysis access in patients at high risk for infection is associated with a high incidence rate of graft infection and rupture, particularly when placed in the thigh position. The routine use of cryopreserved vein graft in the thigh should be avoided. The in situ replacement of infected polytetrafluoroethylene arteriovenous grafts with cryopreserved vein should be considered if alternative sites for new access placement are unavailable. (J Vasc Surg 2002;36:464-8.)

Assessment of sonographic venous peak systolic velocity in detecting hemodialysis arteriovenous graft stenosis

There is no single effective means of assessing arteriovenous access function, although monitoring hemodialysis venous pressure (VP) or measuring access recirculation may be of some benefit. The present study assesses prospectively the efficacy of following the peak systolic velocity (PSV) as a single measure to detect arteriovenous graft (AVG) stenosis. PSV was measured in 12 patients after new AVG placement and at approximately 2-month intervals. Angiography was also performed after new graft placement and when PSV was elevated to greater than 200 cm/sec, hemodialysis access VP increased to greater than 150 mm Hg on three consecutive readings, or access recirculation increased to greater than 11%. PSV was then compared with results from angiography, VP monitoring, and access recirculation. The 12 patients underwent 34 PSV studies, followed by angiography on 25 occasions. Each patient underwent at least one angiogram. Each abnormal PSV value was confirmed with the finding of stenosis on angiogram, except for two patients with PSVs greater than 400 cm/sec and normal angiography results. VP and recirculation were not elevated. During this period, two patients developed thrombosis of the AVG, and two patients underwent angioplasty with improvement in PSV. We conclude that elevations in PSV measured at the venous anastomosis are an effective means of screening for AVG stenosis, AVG stenosis can occur early after AVG placement, and elevated VP and recirculation are late findings in AVG dysfunction.

US vascular mapping before hemodialysis access placement.

To prospectively assess the effect of preoperative ultrasonographic (US) mapping on surgical selection, placement of arteriovenous fistulas (AVFs) and grafts, and negative surgical exploration rates. US assessment of the upper extremity arterial and venous anatomy was performed in 70 patients with chronic renal failure before surgical evaluation. The surgeon documented the planned access procedure, which was based on physical examination results, and then reviewed the US preoperative mapping report. The surgical procedure and outcome were recorded. Fifty-two of the 70 patients who underwent mapping had vascular access placement. Preoperative US mapping resulted in a change in the planned surgical procedure in 16 (31%) of the 52 patients. An AVF rather than the planned graft was placed in eight (15%) patients. The AVF placement rate increased from 32% (126 of 395 patients) to 58% (30 of 52 patients). Unsuccessful surgical explorations decreased from 11% (28 of 256) to 0%. Preoperative US mapping before hemodialysis access placement can result in a change in surgical management, with an increased number of AVFs placed and an improved likelihood of selecting the most functional vessels preoperatively. Further study is needed to determine longer term outcomes.

Changes in the practice of angioaccess surgery: Impact of dialysis outcome and quality initiative recommendations

Purpose: Recommendations recently published by the National Kidney Foundation—Dialysis Outcome and Quality Initiative (DOQI) included an appeal for increased use of native arteriovenous fistulas (NAVFs) to improve overall patency and contain angioaccess costs. We evaluated the impact of the DOQI recommendations on angioaccess surgery and its outcome at our institution. Methods: From June 1996 to April 1999, 483 angioaccess procedures were performed on 247 patients. There were 133 men and 114 women, with an average age ranging from 28 to 95 years (mean age, 69 ± 0.59 years). Risk factors included smoking in 143 patients (58%), diabetes mellitus in 135 patients (55%), hypertension in 150 patients (61%), and coronary artery disease in 98 patients (40%). The patients were divided in two groups. Group I (pre-DOQI) included patients who had angioaccess procedures between June 1996 and November 1997, and group II (post-DOQI) included patients who had angioaccess procedures between December 1997 and April 1999. The types of procedures performed included placement of arteriovenous grafts (AVGs) in 122 patients (25%), creation of NAVFs in 99 patients (20%), revision of AVGs in 123 patients (25%), and temporary access procedures in 135 patients (28%). Forty-seven of the NAVF procedures were radial-cephalic fistulas (47%), 22 were brachial-cephalic fistulas (23%), and 30 were brachial-basilic fistulas (30%). Patients underwent serial ultrasonography scanning and physical examinations; the mean follow-up period was 9 months. Choice of angioaccess procedures and patency rates before and after implementation of the DOQI recommendations were compared. Results: There was a significant increase in the use of NAVFs after implementing DOQI recommendations (5% vs 68%, P < .001). The 1-year primary patency rate of AVGs was less than that of arteriovenous fistulas (54% vs 85%, P <.001). During the study period, the percentage of AVGs placed at our institution that required revision (59%; 72 of 123) was higher than that of NAVFs that required revision (4%; 4 of 99; P < .001). There was no significant difference in the maturation rates of radial-cephalic fistulas (75%), brachial-cephalic fistulas (91%), and brachial-basilic fistulas (87%). Conclusion: By adopting the DOQI recommendations, we used NAVFs more often. This resulted in superior patency rates, compared with synthetic grafts. The liberal use of preoperative duplex venous mapping further increased NAVF use, surpassing the DOQI expectations for primary arteriovenous fistulas. Additionally, fewer revisions were required. (J Vasc Surg 2000;31:84-92.)

Dyspnea During Interscalene Block After Recent Coronary Bypass Surgery

Dyspnea During Interscalene Block After Recent Coronary Bypass Surgery

A multidisciplinary approach to hemodialysis access: Prospective evaluation

Dialysis access procedures and complications represent a major cause of morbidity, hospitalization and cost for chronic dialysis patients. To improve outcomes and reduce the cost of hemodialysis access procedures we developed a multidisciplinary approach, involving nephrologists, access surgeons, and radiologists. A full-time dialysis access coordinator scheduled all access procedures with the surgeons and radiologists, and tracked outcomes. A computerized database was developed for prospective documentation of procedures and complications. Confidential, detailed analyses and recommendations for improvements were provided periodically to the surgeons and radiologists. The major changes arising from the multidisciplinary approach were as follows: (1) The approach to clotted grafts evolved from an inpatient surgical procedure to an outpatient radiologic procedure. The immediate technical success rate of graft declots increased from 48% to 69%. (2) Elective placement of arteriovenous (A-V) grafts evolved from a three-day inpatient hospitalization to a largely outpatient procedure. The proportion of A-V grafts placed as same day surgery or outpatient surgery increased from 16% to 81%. (3) Surgical complications of new A-V graft surgery decreased from 25% to 11%. (4) Aggressive detection and correction of graft stenosis decreased the incidence of graft thrombosis by 60%, from 0.70 to 0.28 events per patient-year. (5) The proportion of native A-V fistula construction in new dialysis patients increased from 33% to 69%. In conclusion, an integrated multidisciplinary approach markedly reduced surgical complications of access surgery and decreased access failures. These improvements occurred despite a marked decrease in hospitalization for access procedures, with a substantial cost saving.

Preservation of hemodialysis access with central obstruction

To salvage the arteriovenous grafts in limbs with brachio-axillary-subclavian vein stenosis/occlusion and to avoid the need of subclavian/jugular catheter for temporary dialysis, the following management and preventive measures were adopted. Thirty-eight patients (17 M, 21 F), mean age of 59 years, underwent successful brachio-jugular and jugular-jugular bypasses for brachio-axillary-subclavian and brachiocephalic stenosis/thrombosis not amendable with balloon angioplasty. After a mean follow-up of 42 months, the venous bypass and arteriovenous graft (AVG) remain functional without arm swelling in 32/38 (84.2%) of the patients. A prospective randomized comparison of early AVG cannulation (<3 days) and late cannulation (> 10 days) following AVG placement showed no statistical difference in 36 patients (17 M, 19 F) equally divided into two groups (n = 18). The determinant parameters used for assessment of AVG were compression time for bleeding control, venous back pressure of AVG, hematoma, pseudoaneurysm, infection, and thrombosis of AVG. Venous bypass that circumvents venous outflow occlusion of limb with AVG is durable and effective in AVG preservation and reduction of the limb swelling. Early cannulation of AVG is plausible and without added risks. Subclavian and jugular catheter for temporary dialysis can be avoided.

Reflex Sympathetic Dystrophy Syndrome of the Hand After Placement of an Arteriovenous Graft for Hemodialysis

Reflex sympathetic dystrophy syndrome (RSDS), a complex clinical syndrome characterized by pain and swelling of an affected extremity, is most commonly seen after trauma. We report the case of a woman with diabetes mellitus and chronic renal failure who presented with RSDS 5 months after placement of an arteriovenous (AV) graft for hemodialysis. The temporal relationship between RSDS and the vascular surgery suggests AV graft placement as the precipitating event for the development of RSDS. Treatment with systemic corticosteroids successfully relieved the patient's symptoms. We believe that RSDS should be included in the differential diagnosis of unexplained limb pain and swelling after AV graft placement.

National documentation and information activities in the social sciences in Norway

Purpose: Recommendations recently published by the National Kidney Foundation—Dialysis Outcome and Quality Initiative (DOQI) included an appeal for increased use of native arteriovenous fistulas (NAVFs) to improve overall patency and contain angioaccess costs. We evaluated the impact of the DOQI recommendations on angioaccess surgery and its outcome at our institution. Methods: From June 1996 to April 1999, 483 angioaccess procedures were performed on 247 patients. There were 133 men and 114 women, with an average age ranging from 28 to 95 years (mean age, 69 ± 0.59 years). Risk factors included smoking in 143 patients (58%), diabetes mellitus in 135 patients (55%), hypertension in 150 patients (61%), and coronary artery disease in 98 patients (40%). The patients were divided in two groups. Group I (pre-DOQI) included patients who had angioaccess procedures between June 1996 and November 1997, and group II (post-DOQI) included patients who had angioaccess procedures between December 1997 and April 1999. The types of procedures performed included placement of arteriovenous grafts (AVGs) in 122 patients (25%), creation of NAVFs in 99 patients (20%), revision of AVGs in 123 patients (25%), and temporary access procedures in 135 patients (28%). Forty-seven of the NAVF procedures were radial-cephalic fistulas (47%), 22 were brachial-cephalic fistulas (23%), and 30 were brachial-basilic fistulas (30%). Patients underwent serial ultrasonography scanning and physical examinations; the mean follow-up period was 9 months. Choice of angioaccess procedures and patency rates before and after implementation of the DOQI recommendations were compared. Results: There was a significant increase in the use of NAVFs after implementing DOQI recommendations (5% vs 68%, P < .001). The 1-year primary patency rate of AVGs was less than that of arteriovenous fistulas (54% vs 85%, P <.001). During the study period, the percentage of AVGs placed at our institution that required revision (59%; 72 of 123) was higher than that of NAVFs that required revision (4%; 4 of 99; P < .001). There was no significant difference in the maturation rates of radial-cephalic fistulas (75%), brachial-cephalic fistulas (91%), and brachial-basilic fistulas (87%). Conclusion: By adopting the DOQI recommendations, we used NAVFs more often. This resulted in superior patency rates, compared with synthetic grafts. The liberal use of preoperative duplex venous mapping further increased NAVF use, surpassing the DOQI expectations for primary arteriovenous fistulas. Additionally, fewer revisions were required. (J Vasc Surg 2000;31:84-92.)