Thigh Grafts Research Articles

Abstract No. 204 HeRO graft placement versus central venous stenting for arm swelling ipsilateral to AV access: a cost analysis from the payor’s perspective

In ESRD patients with AV fistulae or grafts, ipsilateral central venous occlusive disease can result in massive arm swelling resulting in significant morbidity. Treatment options include angioplasty, stent placement, access ligation, and more recently conversion of the access to a HeRO graft. Recent literature has demonstrated that conversion to a HeRO graft results in longer primary and secondary patency than central vein stent placement with equivalent efficacy for resolving arm swelling. Existing literature has compared the cost of the HeRO graft to thigh graft or tunneled catheter use, but there is no literature comparing the cost of HeRO graft to alternative strategies for arm swelling.

Long-term outcomes of thigh arteriovenous graft stenting

Background: Stents have been increasingly used for treating venous anastomosis stenosis seen in arteriovenous grafts (AVGs). A major reason for this trend is that stents can potentially confer a better patency rate compared to angioplasty. However, limited data are available about the outcomes of stents that are used to treat thigh AVG dysfunction. This study sought to assess the primary and secondary patency rates of stents used to treat thigh AVGs dysfunction at one year. Methods: This is a retrospective study of dialysis patients who received therapy via thigh grafts (N=50) and underwent stent placement between January 2005 and June 2017 at our center. Data on demographics and baseline characteristics of the study population were collected. The primary and secondary patency rates were defined as the time between stent deployment and the first intervention and second intervention, respectively. Patency and re-intervention rates were estimated using Kaplan-Meier survival analysis. Results: This study included 50 patients with thigh AVGs; mean age was 50.5± 15.5 years; 52% were female; 80% were black; and 90% had hypertension. The main indication for stenting was thrombosis due to venous anastomosis stenosis (74%). The number (mean ± SD) of stents deployed was 1.24 ± 0.8. The primary patency rate at three months and one year was 58.7% and 30.7%. In comparison, the secondary patency rate at three months and one year was 68.2% and 40.7% (p=0.04) Conclusions: Thigh AVG stenting can be successfully used to improve the overall patency rates of failing AVGs.

Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts.

The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage. Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments. All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3months after their final surgery. At 24months follow-up, 90% amputation free survival is still maintained. Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.

Long-term results of thigh arteriovenous dialysis grafts.

A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients. We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented. In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13-79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients' lifetime on dialysis. Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.

Outcomes of Gracilis Muscle Flaps in the Management of Groin Complications after Arterial Bypass with Prosthetic Graft

This study details 2-year outcomes of a modified gracilis muscle flap (GMF) technique in providing tissue coverage for groin complications after arterial bypass surgery with synthetic graft. All patients who developed groin infections after lower extremity arterial bypass with synthetic graft who underwent a GMF technique were included from June 2014 to March 2017 from a prospectively collected, purpose-built institutional database. Modifications to the standard technique included identification of the muscle using ultrasound to ensure precise skip incisions, preservation of the segmental blood supply, widening of the tunnel through which the muscle is retroflexed, placement of a wound vacuum-assisted closure for healing, and lifelong antibiotics. Demographics, laboratory values, bypass procedure, length of stay (LOS), disposition, and 1-, 3-, 6-, 12-, and 24-month follow-up data were collected. Analysis was performed via descriptive statistics. Over the 3-year study period, 22 patients underwent GMF after complications resulted from arterial bypass surgery. Types of bypass included aortobifemoral (32%), axillobifemoral (14%), femoral-femoral (23%), femoral-popliteal or mixed distal (27%), and thigh graft for dialysis (4%). Forty-five percentage of patients presented with graft infection, 50% with wound dehiscence, and 5% with graft disruption and bleeding. Only 23% of patients were candidates for sartorius muscle flap at the time of their initial procedure. The average case length was 64+19min. Sixty-four percentage of patients were discharged home with home health care and the remainder to a skilled nursing facility. The average LOS was 6.1+3.4days. Fifty-four percentages of wounds were healed at 1month and 100% at 3months with adjunctive vacuum-assisted closure therapy and lifelong antibiotics. Sixty percentage of patients were still alive at 24months, with 33% of grafts still patent at that time. Median survival was 18.1months, and median graft patency was 17.9months. GMF is a safe and effective treatment for groin complications after arterial bypass surgery with synthetic graft. Owing to its versatility, area of coverage, ease of use, and durability, it potentially should be considered as a primary form of muscle coverage for groin complications.

Thigh arteriovenous grafts. Quantitative comparison with alternative options: A meta-analysis.

Thigh arteriovenous grafts are required in a number of patients with exhausted upper extremity veins and comprise 1%-5% of the total access procedures performed. Alternative autogenous lower extremity options are the rarely used sapheno-tibial arteriovenous fistulae, the saphenous vein transpositions, and the femoral vein transpositions. The latter have proven to be the most durable lower limb access procedures, with low infection rates and their primary patency rates ranged from 74% up to 87% at 2 years. Synthetic thigh grafts are suitable for patients who are not good candidates for any upper limb or any autogenous lower limb access and their secondary patency rates ranged from 54% up to 83% at 2 years. Thigh grafts often get infected and their average weighed infection rate in 920 such grafts included in eight large series was 22.9%. A literature search was performed to evaluate thigh grafts compared with alternative options using meta-analysis. Lower limb accesses were found superior compared to HeRO® device regarding 1-year primary failure rate (odds ratio = 0.28, confidence interval = 0.09-0.88, p = 0.03) and additionally autogenous lower limb accesses were found superior compared to thigh grafts regarding the 1-year primary failure rate (odds ratio = 6.54, confidence interval = 2.29-18.72, p = 0.0005).

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

A comparison of patency and interventions in thigh versus Hemodialysis Reliable Outflow grafts for chronic hemodialysis vascular access

With improvements in medical management and survival of patients with end-stage renal disease, maintaining durable vascular access is increasingly challenging. This study compared primary, assisted primary, and secondary patency, and procedure-specific complications, and evaluated whether the number of interventions to maintain or restore patency differed between prosthetic femoral-femoral looped inguinal access (thigh) grafts and Hemodialysis Reliable Outflow (HeRO; Hemosphere Inc, Minneapolis, Minn) grafts. A single-center, retrospective, intention-to-treat analysis was conducted of consecutive thigh and HeRO grafts placed between May 2004 and June 2015. Medical history, interventions to maintain or restore patency, and complications were abstracted from the electronic medical record. Data were analyzed using parametric and nonparametric statistical tests, Kaplan-Meier survival methods, and multivariable proportional hazards regression and logistic regression. Seventy-six (43 thigh, 33 HeRO) grafts were placed in 61 patients (54% male; age 53 [standard deviation, 13] years). Median follow-up time in the intention-to-treat analysis was 21.2months (min, 0.0; max, 85.3months) for thigh grafts and 6.7months (min, 0.0; max, 56.3months) for HeRO grafts (P= .02). The groups were comparable for sex, age, coronary artery disease, diabetes mellitus, peripheral vascular disease, and smoking history (all P ≥ .12). One thigh graft (2%) and five HeRO (15%) grafts failed primarily. In the intention-to-treat analysis, patency durations were significantly longer in the thigh grafts (all log-rank P ≤ .01). Point estimates of primary patency at 6months, 1year, and 3years were 61%, 46%, and 4% for the thigh grafts and 25%, 15%, and 6% for the HeRO grafts. Point estimates of assisted primary patency at 6months, 1year, and 3years were 75%, 66%, and 54% for the thigh grafts and 41%, 30%, and 10% for the HeRO grafts. Point estimates of secondary patency at 6months, 1year, and 3years were 88%, 88%, and 70% for the thigh grafts and 53%, 43%, and 12% for the HeRO grafts. There were no differences in ischemic (P= .63) or infectious (P= .79) complications between the groups. Multivariable logistic regression demonstrated that after adjusting for follow-up time, HeRO grafts were associated with an increased number of interventions (P= .03). Thigh grafts have significantly better primary, assisted primary, and secondary patency compared with HeRO grafts. There is no significant difference between thigh grafts and HeRO grafts in ischemic or infectious complications. Our logistic regression model demonstrated an association between HeRO grafts and an increased number of interventions to maintain or restore patency. Although HeRO grafts may extend the use of the upper extremity, thigh grafts provide a more durable option for chronic hemodialysis.

Management of post burn contracture of neck

Study Design: It is a prospective analytical study. Place and durations: Subjects & methods: 43 patients admitted during JAN 2001 to DEC 2002 who presented with severe functional (25 patients) of cosmetic impairment (27 patients). We selected 4 different options to manage the patients. (1) Release of/or excision + thigh grafts (2) Release of/or excision + wolfm (3)Thick therish + local flap (4) Musculocutaneous flap. Results: Out of 43 patients 27 were females and 16 were male and the age varies from 4-45 years. Out of 28 patients a (1) 25 given satisfactory and excellent results, and 5 out of Six patients a (2) and 4 out of 5 with (3) gave excellent results. To evaluate the outcome of different options for the management of PBNC we are presenting our 2 years experience of PBNC Neck in 43 patients from January 2001 to December 2002 who were admitted through surgical outdoor of Teaching Hospitals of PMC, Faisalabad. In our set up most of the patients presented with severe functional (25 patients) and cosmetic impairments (27 patients out of 43) because of late presentation, delayed treatment, poverty and lack of proper medical facilities. We selected 4 different options to manage these patients accordingly i.e. (1) release or and excision of contracture and thick split skin graft, (2) release or and excision of contracture and full thickness skin graft, (3) thick split skin graft and local flap, (4) musculocutaneous flap, giving satisfactory to excellent results in 25 out of 28 patients, 5 out of 6 patients and 4 out of 5 patients respectively. Thick split skin grafting after release or/and excision of contracture with strict advice of wearing cervical neck collar remained our mainstay of treatment because it was one of the best practical options to deal with severe PBC Neck while other options being reserved for difficult and recurrent cases. Conclusion: Thick split skin grafting is an easy, cost effective, reliable and compliant to the patient. Furthermore thick split skin grafting is a simple procedure whi ch may be carried out by any general surgeon with reserve for referred for the difficult cases.

We Underutilize the Leg Graft.

Once hemodialysis patients have exhausted all option for a permanent vascular access in both upper extremities, they are often relegated at many dialysis centers to permanent catheter dependence with all its attendant complications, including infections, frequent dysfunction, and central vein stenosis. This commentary makes the case that thigh grafts are a far superior alternative to dialysis catheters in many of these patients. Technical graft failure may occur in some patients due to severe femoral artery calcification, but screening for calcification by ultrasound or computerized tomography can reduce the likelihood of a technical failure. Placement of a thigh graft may lead to critical lower extremity ischemia, but preoperative screening for peripheral vascular disease should minimize this possibility. Thigh grafts have comparable secondary patency to that obtained with upper extremity grafts. Finally, although the risk of infection is somewhat higher for thigh grafts than upper extremity grafts, it is still much lower than the risk of catheter-related bacteremia. In summary, thigh grafts should be used much more frequently in patients without an option for an upper extremity access.

Risk Evaluation of Immediate Surgical Failure During Thigh Hemodialysis Graft Placement by Sonographic Screening.

The purpose of this study was to determine whether preoperative sonographic evaluation of vascular diameters and calcification identifies patients at risk for immediate technical failure of thigh hemodialysis grafts. A retrospective analysis of 143 chronic hemodialysis patients who underwent thigh graft placement was performed. All patients underwent preoperative sonography to assess arterial and venous waveforms and vascular diameters. The degree of arterial calcification was assessed retrospectively. Patient characteristics and graft outcomes were examined. Statistical analyses were performed, with P< .05 considered clinically significant. Sonography identified no or mild arterial calcification in 113 of 143 patients (79%) and moderate to severe calcification in 30 of 143 patients (21%). Primary surgical technical failure occurred in 23% of patients (7 of 30) with moderate to severe calcification, compared to 3.5% (4 of 113) of those with no or mild calcification (hazard ratio, 6.59; 95% confidence interval, 2.06-21.05; P = .002). Cumulative graft survival (time to permanent failure) was shorter in patients with moderate to severe arterial calcification (3-year graft survival, 37% versus 56%; hazard ratio, 2.32; 95% confidence interval, 1.48-6.69; P= .003) but was not significantly associated with venous (P= .82) or arterial (P = .43) diameters. Preoperative sonographic assessment of thigh vessel diameters and calcification can identify patients who may be at risk for immediate technical graft failure and decreased cumulative graft survival. The use of sonography as a screening examination may improve preoperative assessment and surgical planning of hemodialysis thigh grafts.

Swallowing outcomes following primary surgical resection and primary free flap reconstruction for oral and oropharyngeal squamous cell carcinomas: a systematic review protocol

Swallowing outcomes following primary surgical resection and primary free flap reconstruction for oral and oropharyngeal squamous cell carcinomas: a systematic review protocol

Management and outcomes of dialysis access-associated steal syndrome

Dialysis access-associated steal syndrome (DASS) complicates arteriovenous access surgery. We describe a 10-year experience with the surgical management of DASS. DASS operations were retrospectively reviewed from July 2003 to July 2013 from a single academic institution. Demographics, symptoms, surgical details, and outcomes were collected. A total of 201 patients had 218 episodes of DASS. Mean age was 65 years, and 62% were women. DASS was caused by 175 arteriovenous fistulas (80%), 41 upper extremity prosthetic grafts (19%), and two thigh grafts (1%); 87% were brachial artery based. A portion (22%) were referred for DASS from outside practices. All patients had grade 2 (48%) or grade 3 (52%) DASS; 92% (185) were available for follow-up, with a median time to first follow-up of 23 days. Surgical procedures included ligation (73), distal revascularization with interval ligation (DRIL) (59), revision using distal inflow (RUDI) (21), banding (38), proximalization of arterial inflow (12), and distal radial artery ligation (13). There were no differences in preoperative comorbidities between treatment groups. The 30-day complications included continued steal, thrombosis, bleeding, infection, and mortality. Ligation and DRIL were performed most often for grade 3 steal. Ligation and banding were performed most acutely (median time to intervention after access creation of 39 and 24 days vs DRIL and RUDI at 97 and 100 days). Fistula preservation was 0% for ligation, 100% for DRIL, 95% for RUDI, and 89% for banding (P < .01). Improvement of symptoms ranged from 75% (banding) to 98% (DRIL) (P = .005). Women were less likely to have DRIL but more likely to have ligation (P = .001). Complications were highest in the banding (49%) and RUDI (37%) groups. Average mortality was 3.5%, with no significant differences among groups. During the study period, 3287 access procedures were performed, and access volume steadily increased (2003-2008, 1312 access creations; 2008-2013, 1975). Percentage of fistulas (79% vs 86%), incidence of steal (4% vs 6%), and percentage of DRILs (25% vs 28%) were consistent across the two study periods. DRIL and ligation were performed in patients with the most severe symptoms. Compared with ligation, DRIL has equal symptom resolution, no increase in complications, and fistula preservation. Compared with banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the preferred procedure for management of DASS in patients with a functioning autologous fistula who can tolerate a major operation.

Long-term Outcomes of Arteriovenous Thigh Grafts in Hemodialysis Patients

Arteriovenous thigh grafts are a potential vascular access option in hemodialysis patients who have exhausted all upper-limb sites. This study compared the outcomes of thigh grafts with outcomes obtained with dialysis catheters. A prospective vascular access database was queried to identify 209 thigh grafts placed from January 1, 2003, to June 30, 2011. The following were calculated: secondary graft survival (from graft creation to permanent failure), assisted primary graft survival (from graft creation to first thrombosis), and infection-free graft survival (from graft creation to first graft infection). Graft outcomes were compared with those observed with 472 tunneled internal jugular dialysis catheters. The median duration of patient follow-up was 340 days for grafts and 91 days for catheters. The surgical technical failure rate of thigh grafts was 8.1% and was higher in patients with vascular disease (hazard ratio [HR], 2.94; 95% confidence interval [CI], 1.07-8.04; P=0.03). Secondary and assisted primary graft survival rates at 1, 2, and 5 years were 62%, 54%, and 38% and 38%, 27%, and 17%, respectively. Infection-free graft survival rates at 1, 2, and 5 years were 79%, 73%, and 61%. Secondary survival was much worse for dialysis catheters than thigh grafts (HR, 4.44; 95% CI, 3.65-5.22; P<0.001). Likewise, infection-free survival was far worse for catheters than for thigh grafts (HR, 3.77; 95% CI, 2.80-4.82; P<0.001). Thigh grafts are a viable vascular option in patients who have exhausted upper-extremity options. Outcomes with thigh grafts are superior to those obtained with dialysis catheters.

Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model

BackgroundThe Hemodialysis Reliable Outflow (HeRO) dialysis access device is a permanent tunneled dialysis graft connected to a central venous catheter and is used in patients with end-stage dialysis access (ESDA) issues secondary to central venous stenosis. The safety and effectiveness of the HeRO device has previously been proven, but no study thus far has compared the cost of its use with tunneled dialysis catheters (TDCs) and thigh grafts in patients with ESDA. Materials and methodsA decision analytic model was developed to simulate outcomes for patients with ESDA undergoing placement of a HeRO dialysis access device, TDC, or thigh graft. Outcomes of interest were infection, thrombosis, and ischemic events. Baseline values, ranges, and costs were determined from a systematic review of the literature. Total costs were based on 1year of post-procedure outcomes. Sensitivity analyses were conducted to test model strength. ResultsThe HeRO dialysis access device is the least costly dialysis access with an average 1-year cost of $6521. The 1-year cost for a TDC was $8477. A thigh graft accounted for $9567 in a 1-year time period. ConclusionsThe HeRO dialysis access device is the least costly method of ESDA. The primary determinants of cost in this model are infection in TDCs and leg ischemia necessitating amputation in thigh grafts. Further study is necessary to incorporate patient preference and quality of life into the model.

Arteriovenous Graft Infection

There are a limited number of publications on the features of arteriovenous graft infection in hemodialysis patients. The authors compared the clinical presentation, complications, and outcomes of infections of thigh and upper extremity grafts. The authors queried a prospective access database at a large university medical center and identified 132 patients with graft infections (40 in the thigh and 92 in the upper extremity) requiring surgical excision. The authors collected information regarding the microbiology, complications, and clinical outcomes. The two graft groups were similar in age, gender, race, and frequency of diabetes. The median age of infected grafts was 162 days for thigh grafts versus 168 days for upper extremity grafts (P = 0.35). Thigh graft infections were more likely than upper extremity graft infections to be caused by a Gram-negative rod (31% versus 4%; P = 0.003), and more likely to result in a metastatic infection (15% versus 3%; P = 0.02). The duration of hospitalization associated with graft infection was similar (10.8 ± 5.4 versus 8.7 ± 6.3 days; P = 0.09). Finally, median catheter dependence was longer after thigh graft than upper arm graft infections (319 versus 237 days; P = 0.04). As compared with upper extremity graft infections, thigh graft infections requiring excision are more likely to be caused by Gram-negative bacteria and to result in serious metastatic complications. These differences may require different empiric antibiotics and a higher index of suspicion for infection in hemodialysis patients with thigh grafts.

332 Arterio-Venous Graft Infections: A Comparison of Thigh and Upper Extremity Grafts

332 Arterio-Venous Graft Infections: A Comparison of Thigh and Upper Extremity Grafts

Thigh Grafts Contribute Significantly to Patients' Time on Dialysis

Thigh grafts are placed in hemodialysis patients who have exhausted all arm access sites. The goal of this study was to compare the survival, complication rates, and overall contribution of thigh grafts with arm grafts and fistulas in patients with at least one functional thigh graft during their dialysis history. This longitudinal review of a prospectively acquired clinical database included 85 thigh graft recipients. The rates of survival, thrombosis, infection, and other complications were determined for a total of 268 fistulas, arm grafts, and thigh grafts placed in these patients. In this patient subset, thigh graft primary failure rate was lower than arm grafts and fistulas (3 versus 13 and 61%, respectively). Excluding primary failures, thigh grafts survived longer than both arm grafts and mature fistulas (53 versus 14 and 32%, at 3 years; 47 versus 3 and 11% at 5 years). Thigh grafts had a lower thrombosis rate than arm grafts (0.543 versus 1.457/patient-year) but similar rates of loss as a result of infection and surgical revision. In patients with previous arm accesses, thigh grafts contributed 51% of total dialysis time compared with 38 and 11% for arm grafts and fistulas. Thigh grafts provide long-term, thrombosis- and infection-free dialysis access for patients with exhausted arm access sites. The decision for thigh graft placement should, therefore, be made as soon as there is evidence for unavailability of arm access sites so that catheter use can be minimized.

Infection of Hemodialysis Arteriovenous Grafts

Prosthetic arteriovenous grafts (AVG) are bedeviled by significant infectious complications. This study was to determine the infectious complications of prosthetic AVG and review the relevant literature. All prosthetic AVG inserted between January 2000 to December 2007 were studied. Data on age, sex, date of graft insertion, indication for AVG, site of graft insertion, date of graft related infection, treatment and outcome for graft and patients were analyzed. There were 84 AVG inserted into 58 patients. Thigh AVG accounted for 55% of cases whereas upper arm AVG was inserted in 39%. Thirteen (17.3%) AVG were associated with one or more episodes of infection. The infection rate for SynerGraft (50%) was statistically significantly different from that of PTFE (12%) - Yates' x2=6.164; df=1; p=0.013. The rate of infection was higher for thigh grafts (9/37) compared to other sites (4/34), but the difference was not statistically significant (Yates' x2=1.123; df=1; p=0.289). Only one death was directly related to AVG infection in this series. Infectious complications of AVG require prompt surgical or radiological intervention to save life or access. The need to excise an infected graft completely is sometimes counterbalanced by the compelling need to provide vascular access for hemodialysis in a patient with limited access options.

Editorials: Thigh Grafts: A Preferable Alternative to Catheters when Upper Extremity Access Sites are Exhausted

Hemodialysis patients with failed upper extremity (arm) access sites comprise 5-10% of the dialysis population. In these patients, arm vessels are either unsuitable for access placement due to trauma or peripheral vascular disease, or have been exhausted following dialysis usage. Synthetic grafts in the lower extremity (thigh) would benefit these patients, but surgeons are often reluctant to place them, due to concerns of infection and vascular complications. As a result, these patients receive tunneled central venous catheters as their permanent dialysis access. Recent studies have shown, however, that survival and complication rates of thigh grafts are similar to arm grafts and fistulas. Moreover, thigh grafts have lower infection and mortality rates than catheters and provide higher blood flows and dialysis adequacy. In this editorial we argue that thigh grafts are the better option in patients who have lost all arm access sites; they should be placed in preference to tunneled central venous catheters.