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Russu E, Munteanu AC, Arbănași EM, Szanto LA, Bartus R, Florea E, Bandici BC, Arbănași EM, Ion AP, Cordoș BA, Serac G, Ujlaki-Nagi AA, Ciucanu CC, Mureșan AV. Out-Patient versus In-Patient Arteriovenous Fistula Creation for Dialysis: Assessing Cost-Effectiveness Alongside Clinical Implications. Healthcare (Basel) 2024; 12:1102. [PMID: 38891176 PMCID: PMC11171627 DOI: 10.3390/healthcare12111102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
(1) Background: The surgical procedure to create an arteriovenous fistula (AVF) can be performed in either an ambulatory or in-patient hospital setting, depending on the case's complexity, the anesthesia type used, and the patient's comorbidities. The main scope of this study is to assess the cost-effectiveness and clinical implications of surgically creating an AVF in both ambulatory and in-hospital settings. (2) Methods: We conducted a retrospective observational study, in which we initially enrolled all patients with end-stage kidney disease (ESKD) admitted to the Vascular Surgery Department, Emergency County Hospital of Targu Mures, Romania, to surgically create an AVF for dialysis, between January 2020 and December 2022. The primary endpoint of this study is to assess the cost-effectiveness of surgically creating an AVF in an ambulatory vs. in-hospital setting by comparing the costs required for the two types of admissions. Further, the 116 patients enrolled in this study were divided into two groups based on their preference for hospitalization: out-patients and in-patients. (3) Results: Regarding in-patient comorbidities, there was a higher prevalence of peripheral artery disease (PAD) (p = 0.006), malignancy (p = 0.020), and previous myocardial infarction (p = 0.012). In addition, active smoking (p = 0.006) and obesity (p = 0.018) were more frequent among these patients. Regarding the laboratory data, the in-patients had lower levels of white blood cells (WBC) (p = 0.004), neutrophils count (p = 0.025), lymphocytes (p = 0.034), and monocytes (p = 0.032), but there were no differences between the two groups regarding the systemic inflammatory biomarkers or the AVF type. Additionally, we did not register any difference regarding the outcomes: local complications (p = 0.588), maturation failure (p = 0.267), and primary patency (p = 0.834). In our subsequent analysis, we discovered no significant difference between the hospitalization type chosen by patients regarding AVF primary patency failure (p = 0.195). We found no significant association between the hospitalization type and the recorded outcomes (all ps > 0.05) in both multivariate linear regression and Cox proportional hazard analysis. (4) Conclusions: In conclusion, there are no significant differences in the clinical implications, short-term and long-term complications of AVF for out-patient and in-patient admissions. Additionally, we found no variation in the costs associated with laboratory tests and surgical supplies for an AVF creation. Therefore, it is safe to perform ambulatory AVFs, which can reduce the risk of hospital-acquired infections and provide greater comfort to the patient.
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Affiliation(s)
- Eliza Russu
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (E.R.); (C.C.C.); (A.V.M.)
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | | | - Emil-Marian Arbănași
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (E.R.); (C.C.C.); (A.V.M.)
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
- Regenerative Medicine Laboratory, Centre for Advanced Medical and Pharmaceutical Research (CCAMF), George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania;
| | | | - Reka Bartus
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (E.R.); (C.C.C.); (A.V.M.)
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | - Elena Florea
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
| | | | - Eliza-Mihaela Arbănași
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Alexandru Petru Ion
- George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Bogdan Andrei Cordoș
- Regenerative Medicine Laboratory, Centre for Advanced Medical and Pharmaceutical Research (CCAMF), George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania;
- Centre for Experimental Medical and Imaging Studies, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Gabriel Serac
- Department of Anatomy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | | | - Claudiu Constantin Ciucanu
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (E.R.); (C.C.C.); (A.V.M.)
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
- Doctoral School of Medicine and Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania
| | - Adrian Vasile Mureșan
- Department of Vascular Surgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540139 Targu Mures, Romania; (E.R.); (C.C.C.); (A.V.M.)
- Clinic of Vascular Surgery, Mures County Emergency Hospital, 540136 Targu Mures, Romania
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2
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Hejna EE, Chang J, Terranella SL, Trawczynski MH, Hollinger EF, Jensik SC, Olaitan O, Hertl M, Chan EY. End-to-end anastomosis as a superior repair type to prevent recurrence of arteriovenous fistula aneurysms and improve patency outcomes. J Vasc Access 2024; 25:531-537. [PMID: 36189749 DOI: 10.1177/11297298221125609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Arteriovenous fistulae (AVF) complicated by aneurysms are repaired through several mechanisms. Little is known about risk factors for aneurysm recurrence or the efficacy of subsequent repair of recurring aneurysms. METHODS About 291 patients underwent AVF aneurysm repair between 2009 and 2019 at a large urban medical center. Patients who underwent staged repair, had a primary graft with pseudoaneurysm, were status-post kidney transplant, or using other dialysis access at the time of repair were excluded. One hundred sixty-two patients were included in the study, of which 52 developed a secondary aneurysm. Chi-square and t-test analyses were used to compare demographics. Multivariate logistic regression was used to examine independent risk factors for aneurysm recurrence. Of the 52 patients with recurrent aneurysms, 41 were repaired again. Patency was examined for each group 1 year postoperatively. RESULTS Patients without secondary aneurysms were more likely to have a Charlson Comorbidity Index score ⩾5 (p = 0.045). Males were 2.8 times more likely to develop a secondary aneurysm compared to females (p = 0.023). Patients who underwent elective compared to emergent or urgent surgery for primary aneurysms were significantly less likely to recur (OR = 0.222; p = 0.016). Primary aneurysms repaired by end-to-end anastomosis, compared to aneurysmorrhaphy or graft, were significantly less likely to recur (OR = 0.239; p = 0.041). Among patients with secondary aneurysms, those repaired via end-to-end anastomosis had a significantly higher primary patency rate 1 year postoperatively (p = 0.024). Secondary aneurysm repairs exhibited 1-year primary and secondary patency rates of 51.2% and 82.9%, respectively. CONCLUSIONS End-to-end anastomosis reduces risk of recurrence and demonstrates superior patency rates when repairing recurrent aneurysms. It remains unclear why some patients are prone to aneurysm recurrence, however continued attempts to repair existing vascular access are proven to be successful.
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Affiliation(s)
- Emily E Hejna
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jaimie Chang
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Samantha L Terranella
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew H Trawczynski
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Edward F Hollinger
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Stephen C Jensik
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Oyedolamu Olaitan
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Martin Hertl
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Edie Y Chan
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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Aronhime S, Balan S, Avital Y, Cherniavsky A. Pave and Pop: A novel addition to the endovascular treatment of hemodialysis access aneurysms. J Vasc Access 2023:11297298231201665. [PMID: 37990883 DOI: 10.1177/11297298231201665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Hemodialysis access sites can be complicated by both true and false aneurysms with significant potential morbidity. Aneurysms have traditionally been treated by a variety of surgical methods. Less commonly, endovascular treatment with stent graft placement has been used as an alternative to open surgery. METHODS Four patients with symptomatic aneurysmal disease in the hemodialysis access site were treated. All patients had stent grafts (SGs) placed across the diseased segment. Once the diseased segment was excluded, blood was drained from the aneurysm with an 18 g needle. All patients were seen in clinic at 1- and 3-months post procedure. RESULTS All patients were able to receive adequate hemodialysis post procedure. Two patients were cannulated via the SG after 1 month. No aneurysm refilling was seen. No SG infections or fractures were seen. CONCLUSION A novel addition to the endovascular treatment of aneurysmal disease in hemodialysis patients is described, that both excludes the aneurysm and drains it, providing improvement in the aesthetic appearance of the access site.
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Affiliation(s)
- Shimon Aronhime
- Department of Interventional Radiology, Shamir Medical Center (Assaf Harofeh), Tel Aviv University, Tzrifin, Israel
| | - Shmuel Balan
- Department of Interventional Radiology, Shamir Medical Center (Assaf Harofeh), Tel Aviv University, Tzrifin, Israel
| | - Yaniv Avital
- Department of Interventional Radiology, Shamir Medical Center (Assaf Harofeh), Tel Aviv University, Tzrifin, Israel
| | - Alexei Cherniavsky
- Department of Interventional Radiology, Shamir Medical Center (Assaf Harofeh), Tel Aviv University, Tzrifin, Israel
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Higgins MCSS, Diamond M, Mauro DM, Kapoor BS, Steigner ML, Fidelman N, Aghayev A, Chamarthy MRK, Dedier J, Dillavou ED, Felder M, Lew SQ, Lockhart ME, Siracuse JJ, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. J Am Coll Radiol 2023; 20:S382-S412. [PMID: 38040461 DOI: 10.1016/j.jacr.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Matthew Diamond
- Research Author, Boston Medical Center, Boston, Massachusetts
| | - David M Mauro
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Ayaz Aghayev
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Murthy R K Chamarthy
- Vascular Institute of North Texas, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Julien Dedier
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | - Ellen D Dillavou
- WakeMed Hospital System, Raleigh, North Carolina; Society for Vascular Surgery
| | - Mila Felder
- Advocate Christ Medical Center, Oak Lawn, Illinois; American College of Emergency Physicians
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | | | - Jeffrey J Siracuse
- Boston University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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5
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Płoński A, Płoński AF, Głowiński J. Surgical Management, Prevention and Outcomes for Aneurysms of Arteriovenous Dialysis Fistulas: A Case Series Study and Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6256. [PMID: 37444103 PMCID: PMC10341233 DOI: 10.3390/ijerph20136256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023]
Abstract
The escalating population of individuals afflicted with end-stage renal disease necessitates the provision of secure and efficacious vascular access for hemodialysis, with arteriovenous fistulas representing a preferred option. Nonetheless, the creation of dialysis fistulas may entail complications, including the occurrence of fistula aneurysms that may require surgical intervention. This study included eight patients with large aneurysms of dialysis fistulas and aimed to evaluate the safety and effectiveness of classic, endovascular, or hybrid methods for fistula reconstruction or ligation, depending on the indications. Vascular interventions were performed on patients on chronic hemodialysis and on those in whom hemodialysis was discontinued due to the proper functioning of the transplanted kidney. Performed procedures were considered safe and effective. The reconstructed fistulas provided the patients with patent vascular access, allowing for continued hemodialysis. No re-aneurysmal dilatation of the reconstructed or ligated fistulas was observed. Regular monitoring of dialysis fistulas is crucial to detect complications in time. Guidelines should be established to specify the dimensions at which fistula aneurysm should be excised and whether to remove asymptomatic aneurysms at all. For patients who have undergone kidney transplantation, outlines should indicate when the fistula should be preserved and when it should be ligated.
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Affiliation(s)
- Adam Płoński
- Department of Vascular Surgery and Transplantation, Medical University of Bialystok, 15-276 Bialystok, Poland; (A.F.P.); (J.G.)
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Chang R, Alabi O, Mahajan A, Miller JS, Bhat KR, Mize BM, Khader MA, Teodorescu V. Arteriovenous fistula aneurysmorrhaphy is associated with improved patency and decreased vascular access abandonment. J Vasc Surg 2023; 77:891-898.e1. [PMID: 36368647 DOI: 10.1016/j.jvs.2022.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Upper extremity hemodialysis arteriovenous fistulas (AVFs) can become aneurysmal over time due to repeated cannulation and/or outflow steno-occlusive disease. The optimal surgical management of aneurysmal AVFs (aneurysmorrhaphy vs interposition graft) has remained unclear. METHODS We performed a retrospective review in which current procedural terminology codes were used to screen for patients who had undergone surgical treatment of aneurysmal AVFs between 2016 and 2021 at a single hospital system. The patients were included after a review of the operative reports. The cases were divided by surgical procedure (aneurysmorrhaphy vs interposition graft placement). The patients who had undergone primary AVF ligation or other types of repair were excluded. The primary outcomes were primary assisted and secondary patency, and the secondary outcome was dialysis access abandonment. Multivariable Cox proportional hazards regression was used to test the association between the type of AVF aneurysm repair and the primary and secondary outcomes. RESULTS From 2016 to 2021, 6951 patients had undergone 16,190 dialysis access procedures. Of these procedures, 381 (2.4%) were related to surgical treatment of an aneurysmal AVF. We excluded 58 primary AVF ligation cases and 20 cases involving other types of repair, leaving 303 cases for analysis. These were divided into two groups: aneurysmorrhaphy (n = 123; 41%) and interposition graft (n = 180; 59%). No differences were found between the groups in male gender (68% vs 63%), hypertension (98% vs 98%), or central stenosis (14% vs 22%). The patients who had undergone aneurysmorrhaphy were younger (median age, 54 years vs 59 years); had had a lower rate of diabetes (41% vs 59%), coronary artery disease (41% vs 58%), and congestive heart failure (41% vs 55%); and were less likely to have undergone upper arm access (72% vs 92%). The median follow-up was 11.1 months (interquartile range, 3.6-25.2 months). No differences were found in the incidence of 30-day wound complications (1% vs 3%) or surgical site infections (4% vs 6%). On multivariable Cox regression, interposition graft placement was associated with the loss of primary assisted patency (adjusted hazard ratio [aHR], 2.42; 95% confidence interval [CI], 1.18-4.95), loss of secondary patency (aHR, 3.10; 95% CI, 1.21-7.94), and abandonment of dialysis access (aHR, 3.07; 95% CI, 1.61-5.87; P < .05 for all) at 2 years. CONCLUSIONS AVF aneurysmorrhaphy was associated with improved primary assisted and secondary patency and decreased abandonment of dialysis access. We suggest using aneurysmorrhaphy when AVF aneurysms are indicated for repair. However, individual factors such as patient comorbidities, AVF anatomy, remaining dialysis access options, and patient preference should be considered when planning the surgical approach.
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Affiliation(s)
| | - Olamide Alabi
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Section of Vascular Surgery, Atlanta Veterans Affairs Health Care System, Atlanta, GA
| | - Anuj Mahajan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Jay S Miller
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Karthik R Bhat
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Brandi M Mize
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Mustafa A Khader
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Victoria Teodorescu
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
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Huge Cephalic Vein Aneurysm Post-brachiocephalic Arteriovenous Fistula: Report of a Case and Review of Literature. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03604-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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8
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Revision of Aneurysmal Arteriovenous Access with Immediate Use Graft Is Safe and Avoids Prolonged Use of Tunneled Hemodialysis Catheters. Ann Vasc Surg 2022; 87:295-301. [PMID: 36162627 DOI: 10.1016/j.avsg.2022.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/24/2022] [Accepted: 09/11/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Aneurysmal AVF can pose a difficult treatment dilemma for the vascular surgeon. Prolonged tunneled dialysis catheters (TDC) in patients requiring long-term dialysis are associated with significantly increased mortality compared to arteriovenous fistulas (AVF). We aimed to elucidate the outcomes of aneurysmal AV access revision with aneurysm resection and Artegraft® (LeMaitre, New Brunswick, NJ) Collage Vascular Graft placement to avoid prolonged use of TDCs. METHODS We reviewed all patients with aneurysmal AV access in which the access was revised with aneurysm resection and jump graft placement at a single institution from 2018 to 2021. Outcomes were time to cannulation, reintervention rates, time to reintervention and patency (primary, primary assisted and secondary). Patency rates were estimated with Kaplan-Meier Survival analysis. RESULTS A total of 51 revised aneurysmal AV access in 51 patients were studied, of which 23.5% (n=12) had perioperative TDC placement. Three patients were done for emergent bleeding. The cohort was 62.8% male (n=32) with a median age of 58 years (IQR: 49-67). Most patients had brachiocephalic AVF (n=37 [72.6%]). Median follow up time was 280 days. Median time to cannulation was 2 days. Time to cannulation was significantly longer in patients with perioperative TDC as compared with those without TDC (24 days vs 2 days, P<0.001). Reintervention was required in 41.2% of patients (n=21), at median time of 47 days. At 30, 90, 180, and 365 days, primary patency rates were 84.3%, 78.3%, 66.6%, and 54.9%; primary assisted patency rates were 94.1%, 88.1%, 79.4%, and 79.4% and secondary patency rates were 100%, 97.8%, 91.6% and 91.6% respectively. CONCLUSIONS Revision of aneurysmal AV access (urgent or elective) with Artegraft as jump graft is safe, with acceptable short and mid-term patency results. This allows dialysis patients to continue to have a functional access, decreasing the need for a tunneled catheter and reducing the associated risk of sepsis and increased mortality. This should be considered for all patients with aneurysmal, dysfunctional fistulas to maintain AV access and avoid TDC placement.
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Chang J, Hejna EE, Terranella SL, Trawczynski MH, Hollinger EF, Jensik SC, Olaitan OK, Hertl M, Chan EY. Graft repair of arteriovenous fistula aneurysms is associated with decreased long-term patency. Am J Surg 2022; 224:136-140. [DOI: 10.1016/j.amjsurg.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 02/08/2022] [Accepted: 04/09/2022] [Indexed: 11/01/2022]
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10
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A dual-plane approach for surgical treatment of pseudoaneurysm with arteriovenous fistula in hemodialysis patients. Arch Plast Surg 2021; 48:287-292. [PMID: 34024073 PMCID: PMC8143944 DOI: 10.5999/aps.2020.02068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/24/2021] [Indexed: 11/08/2022] Open
Abstract
Background We report the efficacy of a dual-plane approach using a Dufourmentel skin flap with a purse-string suture of the de-epithelized dermis to manage pseudoaneurysm at the vascular access site for hemodialysis. Methods A retrospective analysis was conducted of 61 patients from 2013 to 2018 with pseudoaneurysms at the arteriovenous fistula or graft who were treated with rhomboid excision, vessel repair with a purse-string suture, and a full-thickness Dufourmentel skin flap. The success rate was defined as the probability of complete wound closure and intact vascular access patency without infection or other complications. Results The success rate was 93.4% at 6 months postoperatively. Complications included newly occurring pseudoaneurysms (n=2), wound dehiscence (n=1) and bleeding (n=1). There were no complications such as stenosis or thrombosis from the procedure. Conclusions A dual-plane approach using a Dufourmentel skin flap with a purse-string suture for vessel repair was shown to be a favorable option for managing stable, small (diameter <2 cm) pseudoaneurysms without infection, rapid expansion, or patency issues of the vascular access.
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11
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Ecevit AN, Karaca OG, Kalender M, Darçın OT. Midterm results of salvage surgery for autogenous dialysis access in aneurysmal arteriovenous fistulas. Ther Apher Dial 2021; 25:947-953. [PMID: 33506997 DOI: 10.1111/1744-9987.13630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Abstract
Autologous arteriovenous fistulas are commonly constructed in patients undergoing hemodialysis for end-stage renal disease. However, they are associated with a high rate of aneurysm formation, and aneurysmal arteriovenous fistulas that have become symptomatic require surgical intervention. This study was performed to evaluate the midterm results of salvage surgery for autogenous dialysis access in patients with aneurysmal arteriovenous fistulas. Of 1326 arteriovenous fistula operations, 81 involving surgery for aneurysmal arteriovenous fistulas between January 2008 and January 2012 were included in this study. The database was searched to identify all complicated arteriovenous fistula patients undergoing surgery for vascular access. The number of complicated arteriovenous fistula surgeries, for example for aneurysms, was greater than the number of patients undergoing surgery to create a new arteriovenous fistula. We performed three different surgical procedures to treat arteriovenous-related aneurysms in our clinic: primary repair, resection and saphenous vein interposition, and resection and polytetrafluoroethylene (PTFE) interposition. We compared the patency rates at the 12- and 24-month follow-ups among these three techniques. The study population consisted of 24 cases of primary repair, 29 cases of resection and saphenous vein interposition, and 30 cases of resection and PTFE graft interposition. True aneurysms occurring in patients undergoing hemodialysis did not require treatment unless they were symptomatic. Arteriovenous access salvage therapy is recommended after the aneurysm has become symptomatic. Symptomatic arteriovenous fistula aneurysms can be treated by maintaining arteriovenous fistula continuity. Moreover, patient safety is ensured by long-term patency.
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Affiliation(s)
- Ata Niyazi Ecevit
- Bilkent City Hospital, Yuksek Ihtisas Kalp Damar Cerrahisi Hastanesi, Ankara, Turkey
| | - Okay Güven Karaca
- Bilkent City Hospital, Yuksek Ihtisas Kalp Damar Cerrahisi Hastanesi, Ankara, Turkey
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12
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Cahalane AM, Sahani VG, Irani Z, Cui J. Arterial diameter following arteriovenous fistula creation predicts aneurysm progression. J Vasc Access 2021; 23:232-239. [PMID: 33438488 DOI: 10.1177/1129729820987383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the relationship between arteriovenous fistula (AVF) arterial diameter (AD) and AVF aneurysm development and progression. METHODS This study identified all patients who underwent fistulograms which demonstrated AVF aneurysms meeting criteria and requiring surgical intervention between 01/01/2014 and 7/30/2016. Patient demographics were collected and AVF dimensions were measured on fistulograms. A control group with nonaneurysmal AVFs who had undergone serial fistulograms between 2013 and 2016 were identified and identical datasets collected. Statistical analysis was performed with STATA 14.0 using student's t-test, Chi square tests and linear regression. RESULTS 45 eligible patients were identified in the AVF aneurysm study group and 24 in the control group, with the mean age of AVF creation being older in the control group (61.8 vs 53 years, p = 0.03). The mean interval between AVF creation and first fistulogram in the study group was 1464 ± 282 days, compared to an interval of 263 ± 101 days in the control group (p = 0.003). The AD on the first fistulogram in those study group patients with aneurysms evident on first fistulogram was greater than in the control group (6.5±1.8 mm vs 5.0 ± 1.8 mm, p = 0.003). The AD on first fistulogram of the study group predicted maximum aneurysm diameter on last fistulogram (r = 0.6, p = 0.03) as well as the interval between first fistulogram and surgical revision (r = -0.33, p = 0.03). CONCLUSION AVF aneurysms are a later complication in access natural history and AD may help to predict their progression.
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Affiliation(s)
- Alexis M Cahalane
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Vivek G Sahani
- Division of Interventional Radiology, Baylor Radiologists, Houston, TX, USA
| | - Zubin Irani
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jie Cui
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Góra R, Bojakowski K, Piasecki A, Kasprzak D, Kaźmierczak S, Andziak P. Aneurysm Excision With Arteriovenous Anastomosis Proximalization for Dialysis Fistula Aneurysm Treatment. Vasc Endovascular Surg 2020; 55:216-220. [PMID: 33280544 DOI: 10.1177/1538574420976723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Dialysis fistula aneurysms are common complications, which require surgical revision in selective cases. The results of aneurysm excision with arteriovenous anastomosis proximalization for the treatment of dialysis fistula aneurysms have been described below. METHODS Patients qualified for the reconstruction of a dialysis fistula aneurysm underwent a duplex ultrasound examination. The diameter, length of the aneurysm, relations with the artery, thrombus presence and blood flow were determined. In the case of favorable anatomical conditions, we performed aneurysm excision with arteriovenous anastomosis proximalization as the procedure of choice. Patients, dialysis access, operative data and the results obtained during a median follow-up of 41 months were then analyzed. FINDINGS Since 2012, we have performed 20 aneurysm excision combined with primary anastomosis as dialysis fistula aneurysm treatment. In 18 patients, aneurysm excision was combined with simple re-anastomosis in the more proximal arterial segment. In 2 autogenous radio-cephalic forearm direct fistulas the aneurysm excision was combined with switching anastomosis type from side-to-end to end-to-end. The 12- and 24-month primary patency rates of corrected fistulas in the observed group were 94.7% and 82.4%, respectively. No early complications were noted. In 7 patients (35%) we observed late complications, which required reintervention or led to access failure. Dialysis fistula thrombosis as an indication for treatment was a significant risk factor for late re-occlusion. DISCUSSION A simple primary reconstruction by arteriovenous anastomosis proximalization and aneurysm excision for the surgical correction of dialysis fistula aneurysms has potential benefits compared to established methods-aneurysmorraphy and aneurysm excision with a vascular prosthesis bypass. The obtained data showed the efficiency, safety and excellent long-term results of this procedure.
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Affiliation(s)
- Rafał Góra
- 2nd Department of Vascular Surgery and Angiology, 359917Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Krzysztof Bojakowski
- 2nd Department of Vascular Surgery and Angiology, 359917Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Antoni Piasecki
- 2nd Department of Vascular Surgery and Angiology, 359917Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Dominika Kasprzak
- 2nd Department of Vascular Surgery and Angiology, 359917Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Stanisław Kaźmierczak
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Piotr Andziak
- 2nd Department of Vascular Surgery and Angiology, 359917Centre of Postgraduate Medical Education, Warsaw, Poland
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14
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Güven C, Uludağ Ö. Proximal Arteriovenous Fistulas in Hemodialysis Patients: Advantages and Disadvantages. Cureus 2020; 12:e11657. [PMID: 33391896 PMCID: PMC7769500 DOI: 10.7759/cureus.11657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: The main objective of the present study is to investigate the advantages and disadvantages of proximal arteriovenous native fistulas. Hemodialysis is indispensable for patients with end-stage renal disease. For this purpose, arteriovenous fistulas (AVFs) are used. Among the native fistulas, distal radiocephalic AVF is the most preferred. However, brachiocephalic AVF (BCAVF) and brachiobasilic AVF with basilic vein transposition (basilic vein transposition arteriovenous fistula [BVTAVF]) can be used for a long time in dialysis patients whose distal vascular bed is depleted. Methods: This is a retrospective study of 117 AVFs (BCAVF and BVTAVF), in patients with end-stage chronic renal disease, that were opened with a surgical technique (2012-2018). The postoperative two-year patency rates, AVF locations, complications, and the advantages and disadvantages of these fistulas are reviewed and recorded in the light of the literature. Results: The mean age of the patients (52 men and 65 women) was 60.6 ± 13.6 years. The percentages of primary patency rates at 3, 6, 9, 12, and 24 months were 96.6%, 93.1%, 92%, 87.4%, and 82.8% in BCAVF patients, and 96.7%, 93.3%, 90%, 86.7%, and 80% in BVTAVF patients, respectively. The percentages of secondary patency rates at 6, 12, and 24 months were 100%, 93.3%, and 86.7% in BCAVF patients, and 100%, 100% and 87.7% in BVTAVF patients, respectively. Fistula thrombosis was seen as the most common complication. The early complication was bleeding/hematoma. As late complications, we encountered steal syndrome, ischemic pain in the relevant extremity, pseudoaneurysm, and high-output heart failure. Conclusion: Proximal AVFs are preferable fistulas with early maturation and high primary patency rates. We believe that relatively high complications can be avoided by opening fistulas with an appropriate surgical technique.
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Affiliation(s)
- Cengiz Güven
- Cardiac/Thoracic/Vascular Surgery, Adıyaman University Faculty of Medicine, Adıyaman, TUR
| | - Öznur Uludağ
- Anesthesiology and Reanimation, Adıyaman University Faculty of Medicine, Adıyaman, TUR
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15
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Almerey TA, Oliver JD, Jorgensen MS, Rinker BD, Farres HA, Hakaim AG, Forte AJ. Upper extremity reconstruction following open surgical repair of giant arteriovenous fistula aneurysm: clinical case and systematic review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020093. [PMID: 33525257 PMCID: PMC7927515 DOI: 10.23750/abm.v91i4.8472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/22/2019] [Indexed: 11/24/2022]
Abstract
Background: Nearly 30% of arteriovenous fistulas (AVFs) located in the upper extremity for hemodialysis access result in short- and long-term adverse effects, such as rupture, necessitating emergent surgical management and extensive soft-tissue reconstruction. With this systematic review, we aimed to compile all reported open surgical techniques used for complicated AVF repair in the upper extremity, the respective soft-tissue reconstructive outcomes, and vascular patency rates at final follow-up. Methods: Using Ovid Medline/PubMed databases, we conducted a review of the English-language literature on AVF aneurysm surgical management in the upper extremity, filtered for relevance to open surgical technique and outcomes in vascular patency after aneurysmal repair at long-term follow-up (≥6 months postoperatively). We include a detailed case of surgical removal of a giant AVF aneurysm and subsequent flap elevation and reconstruction of the upper extremity. Results: Of 150 articles found in the initial search, 19 (from 2010-2017) met inclusion criteria. From the reviewed studies, 675 patients underwent open surgical repair of AVF aneurysm in the upper extremity. Surgical approaches included partial-to-full aneurysm excision, interposition graft, tubularized extracellular matrix, sutured and stapled aneurysmorrhaphy, and stent graft. Rates of vascular patency at repair site ranged from 47% to 100%, with a pooled average of 78% at 6 months or longer postoperatively. Conclusions: For plastic and hand surgeons, aneurysmal ligation and excision is feasible even in severe cases and is associated with overall good vascular and soft-tissue reconstructive outcomes in the upper extremity. (www.actabiomedica.it)
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Affiliation(s)
- Tariq A Almerey
- Division of General Surgery, Mayo Clinic Florida, Jacksonville, FL.
| | | | | | - Brian D Rinker
- Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, FL.
| | - Houssam A Farres
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL.
| | - Albert G Hakaim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL.
| | - Antonio Jorge Forte
- Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.
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16
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Abreo K, Sachdeva B, Abreo AP. To ligate or not to ligate hemodialysis arteriovenous fistulas in kidney transplant patients. J Vasc Access 2020; 22:942-946. [PMID: 33176556 DOI: 10.1177/1129729820970786] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is significant disagreement about maintenance or ligation of arteriovenous fistulas (AVFs) in kidney transplant patients (KTPs). Potential harms from maintaining AVFs are their impact on cardiac function, cosmetic concerns and complications such as bleeding and rupture. High flow AVFs can place a strain on the heart and cause or exacerbate pre-existing cardiac dysfunction. There is an improvement in cardiac function after kidney transplantation independent of vascular access status. Studies comparing cardiac parameters in patients with and without AVFs after renal transplantation have shown conflicting results. Ligation of high flow AVFs in KTPs resulted in improvement in cardiac function and prevention of heart failure. In KTPs with deteriorating renal function and high flow AVFs, banding of the AVFs to reduce flow is an option. Patients who retain AVFs after renal transplant have the advantage of immediate, optimal access should the transplant fail and may have preserved kidney function. The patient's post-transplant kidney function, risk factors for transplant loss, AVF blood flow, and cardiac function play an important role when making the decision to ligate or preserve AVFs.
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Affiliation(s)
- Kenneth Abreo
- LSU Health Shreveport School of Medicine, Shreveport, LA, USA
| | - Bharat Sachdeva
- LSU Health Shreveport School of Medicine, Shreveport, LA, USA
| | - Adrian P Abreo
- LSU Health Shreveport School of Medicine, Shreveport, LA, USA
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17
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Baláž P, Rokošný S, Bafrnec J, Whitley A, O'Neill S. Repair of Aneurysmal Arteriovenous Fistulae: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2020; 59:614-623. [DOI: 10.1016/j.ejvs.2019.07.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 07/09/2019] [Accepted: 07/15/2019] [Indexed: 01/20/2023]
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18
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Derbel B, Koubaa MA, Miri R, Daoued Z, Ben Mrad M, Ziadi J, Denguir R. [Conservative aneurysmorrhaphy for hemodialysis arteriovenous fistula]. JOURNAL DE MEDECINE VASCULAIRE 2019; 44:380-386. [PMID: 31761305 DOI: 10.1016/j.jdmv.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 08/23/2019] [Indexed: 06/10/2023]
Abstract
UNLABELLED The aim of this study was to evaluate the results of conservative surgical treatment of the aneurysmal complications of arteriovenous hemodialysis fistulae and to determine the factors predictive of long- and mid-term patency of treated fistulae. The surgical treatment was mainly based on caliber reduction and reconstruction. METHODS This was a descriptive retrospective study with a five-year duration, going from January 2013 to December 2018. This study included 40 patients presenting aneurysmal complications of their hemodialysis vascular access who were treated with aneurysmorrhaphy. RESULTS The mean age of the aneurysmal-complicated hemodialysis vascular access was 42 months. The indications for treatment were puncture-related difficulties in 42.5% of cases, rapid increase of the aneurysmal diameter in 27.5%, skin thinning in 25% and aneurysmal rupture in 5%. The mean aneurysmal course was 6.6 months with an average diameter of 3.25cm at the moment of management. The initial technical success rate was 100%. Twenty patients had complications in the postoperative period. Patency rates at 3, 6, 12 and 24 months were 89.5%, 81.6%, 71% and 63.1%, respectively. Factors predictive of thrombosis were diabetes (P=0.001), peripheral arterial disease (P=0.003), number of punctures per week (P=0.003) and context of emergency presentation (P=0.001). CONCLUSION Aneurysmorrhaphy seems to be the best conservative surgical treatment for aneurysmal complications of hemodialysis vascular access fistulae. This surgical approach allows us to conserve the native autologous vascular access and spare the patient's venous network.
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Affiliation(s)
- B Derbel
- Faculté de médecine de Tunis, université de Tunis El Manar, 1007, Tunis, Tunisie; Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie.
| | - M A Koubaa
- Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie
| | - R Miri
- Faculté de médecine de Tunis, université de Tunis El Manar, 1007, Tunis, Tunisie; Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie
| | - Z Daoued
- Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie
| | - M Ben Mrad
- Faculté de médecine de Tunis, université de Tunis El Manar, 1007, Tunis, Tunisie; Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie
| | - J Ziadi
- Faculté de médecine de Tunis, université de Tunis El Manar, 1007, Tunis, Tunisie; Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie
| | - R Denguir
- Faculté de médecine de Tunis, université de Tunis El Manar, 1007, Tunis, Tunisie; Service de chirurgie cardiovasculaire, hôpital La Rabta, 1007 Tunis, Tunisie
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19
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Woodford C, Tai E, Mafeld S, Al-Mubarak HA, Jaberi A, Oreopoulos GD. Vascular Reconstruction of a Brachial Artery Aneurysm Proximally to an Arteriovenous Malformation. Vasc Endovascular Surg 2019; 54:75-79. [PMID: 31506016 DOI: 10.1177/1538574419873745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Brachial artery aneurysms and arteriovenous malformations (AVM) are limb-threatening vascular anomalies. This patient presented with a bilobed brachial artery aneurysm in the antecubital fossa proximally to an AVM arising from the dorsal interosseous and ulnar arteries that had been treated with endovascular embolization, leaving the hand solely supplied by the radial artery. The aneurysm continued to increase in size and imaging revealed concomitant thrombus. A femoral vein interposition graft was used to repair the aneurysm, and postoperatively, the patient retained full left arm function.
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Affiliation(s)
| | - Elizabeth Tai
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Husain A Al-Mubarak
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada.,Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Arash Jaberi
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - George D Oreopoulos
- Division of Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.,Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Ontario, Canada
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20
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Antonescu I, McGinigle KL, Crowner JR. A case of aneurysmal dilation of a brachial artery after venous outflow resection. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 4:335-338. [PMID: 30761382 PMCID: PMC6298935 DOI: 10.1016/j.jvscit.2018.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 08/29/2018] [Indexed: 11/15/2022]
Abstract
Dilation throughout the brachial artery in the setting of an arteriovenous fistula is a common occurrence, but focal aneurysmal dilation is not often visualized. Progressive enlargement of a focal arterial segment warrants intervention before negative sequelae. We present the case of a 38-year-old man with history of left upper extremity brachiocephalic fistula who had an enlarged brachial artery and progressive aneurysmal dilation of the distal aspect after ligation and excision of a dilated venous outflow component. The patient was successfully treated with resection and end-to-end reconstruction of the brachial artery, with resolution of pain and improvement in the functionality of his extremity. This case highlights the possible challenges encountered in such situations, when the anatomy is so distorted that it is difficult to clearly delineate on preoperative imaging.
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Affiliation(s)
- Ioana Antonescu
- Correspondence: Ioana Antonescu, MD, MSc, Vascular Surgery, UNCH, 3024 Burnett-Womack Bldg, Chapel Hill, NC 27599
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21
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Hara Y, Sonoda K, Hashimoto K, Fuji K, Yamada Y, Kamijo Y. Influence of arteriovenous fistula on daily living behaviors involving the upper limbs in hemodialysis patients: a cross-sectional questionnaire study. BMC Nephrol 2018; 19:284. [PMID: 30348105 PMCID: PMC6198435 DOI: 10.1186/s12882-018-1097-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 10/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background Arteriovenous fistulae can restrict daily living behaviors involving the upper limbs in hemodialysis patients, but no studies have investigated the detailed effects of an arteriovenous fistula on routine life activities. Accordingly, many medical caregivers are unable to explain the effects of an arteriovenous fistula on daily life, particularly during non-dialysis periods, because they cannot observe them directly. Methods Thirty outpatients undergoing hemodialysis at 2 facilities scored the difficulty due to an arteriovenous fistula in performing 48 living behaviors during non-dialysis and 10 behaviors during dialysis into 5 grades in a comprehensive questionnaire survey. These behaviors were selected based on an open-answer pre-questionnaire administered to the 30 patients beforehand. The scores were also compared between dominant arm and non-dominant arm arteriovenous fistula groups. Results During non-dialysis, the difficulty scores of behaviors restricted out of concern for arteriovenous fistula obstruction (wear a wristwatch, hang a bag on the arm, carry a baby or a dog in the arms, wear a short-sleeved shirt, etc.) increased. The difficulties of “wear a wristwatch” and “hang a bag on the arm” were significantly higher in the non-dominant arm arteriovenous fistula group (both P < 0.05). In contrast, scores related to motor function (write, eat or drink, scratch an itch, etc.) increased remarkably during dialysis because of connection of the arteriovenous fistula to the dialysis machine. The difficulties of “write” and “eat or drink” were significantly higher in the dominant arm arteriovenous fistula group (both P < 0.05). Conclusions Several key daily living behaviors restricted by an arteriovenous fistula were identified in this questionnaire survey. These results will be useful for pre-operative explanation of arteriovenous fistula surgery and arm selection in end-stage renal disease patients. Electronic supplementary material The online version of this article (10.1186/s12882-018-1097-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuuta Hara
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kosuke Sonoda
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kazuaki Fuji
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
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22
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Abreo K, Amin BM, Abreo AP. Physical examination of the hemodialysis arteriovenous fistula to detect early dysfunction. J Vasc Access 2018; 20:7-11. [PMID: 29627998 DOI: 10.1177/1129729818768183] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The maintenance of vascular access patency for end-stage renal disease patients on hemodialysis is necessary for survival. Many nephrologists, nurse practitioners, and nurses have limited experience with the physical examination of the arteriovenous fistula. In this review, we define key terms used in the assessment of an arteriovenous fistula. We discuss the arteriovenous fistula physical exam, including details of inspection, palpation, and auscultation. Using these concepts, we review the abnormal findings that can assist practitioners in determining the location of a stenosis. We review the existing literature that validates physical exam findings with gold standard tests such as ultrasound and angiography. Finally, we review data supporting the value of training physicians and nurses in arteriovenous fistula physical examination.
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Affiliation(s)
- Kenneth Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Bakhtiar M Amin
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Adrian P Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
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23
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Aneurysms in Vascular Access: State of the Art and Future Developments. J Vasc Access 2017; 18:464-472. [DOI: 10.5301/jva.5000828] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 11/20/2022] Open
Abstract
A master class was held at the Vascular Access at Charing Cross (VA@CX2017) conference in April 2017 with invited experts and active audience participation to discuss arteriovenous (AV) vascular access aneurysms, a serious and common complication of vascular access (VA). The natural history of aneurysms in VA is poorly defined, and although classifications exist they are not uniformly applied in studies or clinical practice. True and pseudo aneurysms of AV access occur. Whilst an AV fistula by definition is an abnormal dilatation of a blood vessel, an agreed definition of 18 mm, or 3 times accepted maturation diameter, is proposed. The mechanism of aneurysmal dilatation is unknown but appears to be a combination of excessive external remodeling, wall changes due to injury, and obstruction of outflow. Diagnosis of AV aneurysms is based on physical examination and ultrasound. Venography and cross-sectional imaging may assist and be required for the investigation of outflow stenosis. Treatment of pseudo aneurysms and true aneurysms of VA (AVA) is not evidence-based, but relies on clinical experience and available facilities. In many AVA, a conservative approach with surveillance is suitable, although intervals and modalities are unclear. Avoidance of rupture is imperative and preemptive treatment should aim for access preservation, ideally with avoidance of prosthetic materials. Different techniques of aneurysmorrhaphy are described with good results in published series. Although endovascular approaches and stenting are described with good short-term results, issues with cannulation of stented areas occur and, while possible, this is not recommended, and long-term access revision is recommended.
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