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Ravindhran B, Totty JP, Sidapra M, Lathan R, Carradice D, Chetter IC, Smith GE. Long term outcomes of 'Christmas Tree' banding for haemodialysis access induced distal ischemia: A 13-year experience. J Vasc Access 2024; 25:863-871. [PMID: 36474333 DOI: 10.1177/11297298221141497] [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] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND The reduction in distal arterial flow following arteriovenous fistula (AVF) creation can cause a perfusion deficit known as haemodialysis access induced distal ischemia (HAIDI). Various techniques have been advocated to treat this difficult problem with varying success. We present the long-term outcomes following a novel banding technique. METHODS 46 patients in this cohort from 2008 to 2021 underwent a novel banding procedure using a Dacron™ patch shaped with one slit-end and saw-tooth edges (resulting in a 'Christmas-tree' pattern) to provide a ratchet mechanism to progressively constrict the fistula outflow. Real-time finger perfusion pressure monitoring allowed an accurate reduction in AVF flow whilst increasing distal arterial perfusion pressure. Baseline characteristic were recorded and Kaplan-Meier survival curves were obtained to calculate the post-intervention primary, assisted primary and secondary patency. RESULTS 29 patients presented with rest pain and 11 presented with tissue loss due to distal ischemia. The post-intervention primary access patency was 100%, 98%, 78% and 61% at 30, 60 and 180 days and 1 year respectively. Complete resolution of symptoms was achieved in 74% (n = 34) of patients and a partial response needing no further intervention was achieved in 11% (n = 5) of patients. A Youden index calculation suggested that digital pressures of 41 mm Hg or lower in an open AVF were highly sensitive for symptomatic hand ischemia whereas pressures greater than 65 mm Hg ruled out distal ischemia. CONCLUSION 'Christmas-tree' banding with on table finger systolic pressures is not only an efficacious and durable method for treating HAIDI but also preserves fistula patency.
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Affiliation(s)
| | - Joshua P Totty
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Misha Sidapra
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Ross Lathan
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
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Weaver ML, Holscher CM, Graham A, Reifsnyder T. Distal revascularization and interval ligation for dialysis access-related ischemia is best performed using arm vein conduit. J Vasc Surg 2020; 73:1368-1375.e1. [PMID: 32882351 DOI: 10.1016/j.jvs.2020.07.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/25/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Distal revascularization and interval ligation (DRIL) is an effective approach to the management of hemodialysis access-related ischemia that offers both symptom relief and access salvage. The great saphenous vein (GSV) has been the most commonly used conduit. However, the use of an ipsilateral arm vein will allow for performance of the operation with the patient under regional anesthesia and might result in lower harvest site morbidity than the GSV. We sought to determine the suitability of DRIL using an arm vein compared with a GSV conduit. METHODS All patients who had undergone DRIL from 2008 to 2019 were retrospectively identified in the electronic medical records. The characteristics and outcomes of those with an arm vein vs a GSV conduit were compared using the Wilcoxon log-rank and χ2 tests. Access patency was examined using Kaplan-Meier methods, with censoring at lost to follow-up or death. RESULTS A total of 66 patients who had undergone DRIL for hand ischemia were included in the present study. An arm vein conduit was used in 40 patients (median age, 65 years; 25% male) and a GSV conduit in 26 patients (median age, 58 years; 19% male). No significant differences in comorbidities were found between the two groups, with the exception of diabetes mellitus (arm vein group, 78%; GSV group, 50% GSV; P = .02). No difference in the ischemia stage at presentation was present between the groups, with most patients presenting with stage 3 ischemia. Also, no differences in patency of hemodialysis access after DRIL between the two groups were found (P = .96). At 12 and 24 months after DRIL, 86.9% (95% confidence interval [CI], 68.3%-94.9%) and 82.0% (95% CI, 61.3%-92.3%) of patients with an arm vein conduit had access patency compared with 93.8% (95% CI, 63.2%-99.1%) and 76.9% (95% CI, 43.0%-92.2%) of those with a GSV conduit, respectively. All but one patient had symptom resolution. The incidence of wound complications was significantly greater in the GSV group than in the arm vein group (46% vs 11%; P = .003). DRIL bypass had remained patent in all but one patient in each group, with a median follow-up of 18 months (range, 1-112 months) in the arm vein conduit group and 15 months (range, 0.25-105 months) in the GSV conduit group. CONCLUSIONS DRIL procedures using an arm vein have advantages over those performed with the GSV. In our series, symptom resolution and access salvage were similar but distinctly fewer wound complications had occurred in the arm vein group. Additionally, the use of an arm vein conduit avoids the need for general anesthesia. If an ipsilateral arm vein is available, it should be the conduit of choice when performing DRIL.
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Affiliation(s)
- M Libby Weaver
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
| | | | - Alexis Graham
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Thomas Reifsnyder
- Division of Vascular Surgery, Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md
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Horst VD, Nelson PR, Mallios A, Kempe K, Pandit V, Kim H, Jennings WC. Avoiding hemodialysis access-induced distal ischemia. J Vasc Access 2020; 22:786-794. [PMID: 32715859 DOI: 10.1177/1129729820943464] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Timely creation and maintenance of a safe and reliable vascular access is essential for hemodialysis patients with end-stage renal disease. Hemodialysis access-induced distal ischemia (HAIDI) is a recognized complication of arteriovenous fistulas and grafts that may result in serious or even devastating consequences. Avoiding such complications is clearly preferred over treatment of HAIDI once established. Proper recognition of patients at increased risk of HAIDI includes careful pre-operative evaluation of the patient's medical and surgical history along with physical examination and imaging to determine a plan for creating a functional permanent access while minimizing the risk of distal ischemia. Our aim is to review identifying characteristics of individuals at risk of HAIDI and provide recommendations regarding pre-operative assessment. Vascular access options and techniques are suggested for establishing a functional vascular access without distal ischemia for such patients.
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Affiliation(s)
- Vernon D Horst
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Peter R Nelson
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | | | - Kelly Kempe
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Viraj Pandit
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Hyein Kim
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - William C Jennings
- Division of Vascular Surgery, Department of Surgery, School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
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Gerrickens MWM, Yadav R, Wouda R, Beerenhout CH, Scheltinga MRM. Severe hemodialysis access-induced distal ischemia may be associated with poor survival. J Vasc Access 2020; 22:194-202. [PMID: 32588720 DOI: 10.1177/1129729820933456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Some hemodialysis patients develop hemodialysis access-induced distal ischemia due to insufficient loco-regional perfusion pressure and consequent poor arterial flow. We hypothesized that patients with severe hemodialysis access-induced distal ischemia had worse survival compared with patients with mild or no hemodialysis access-induced distal ischemia. METHODS This single-center retrospective observational cohort study included three groups of prevalent hemodialysis patients with an upper extremity vascular access between 2006 and 2018. Symptomatic patients had signs and symptoms of hemodialysis access-induced distal ischemia and low digital brachial indices (<60%) and were divided into a mild (Grade I-IIa) and a severe hemodialysis access-induced distal ischemia (IIb-IV) group. The control group consisted of hemodialysis patients without signs of hemodialysis access-induced distal ischemia with digital brachial indices ≥60%. Factors potentially related to 4-year survival were analyzed. RESULTS Mild hemodialysis access-induced distal ischemia-patients displayed higher digital brachial indices (n = 23, 41%, ±3) compared with severe hemodialysis access-induced distal ischemia-patients (n = 28, 24%, ±4), whereas controls had the highest values (n = 48, 80%, ±2; p < .001). A total of 44 patients (44%) died during follow-up. Digital brachial index (hazards ratio 0.989 [0.979-1.000] p = .046) was related to overall mortality following correction for presence of arterial occlusive disease (hazards ratio 2.28 [1.22-4.29], diabetes (hazards ratio 2.00 [1.07-3.72], and increasing age (hazards ratio 1.03 [1.01-1.06] as was digital pressure (hazards ratio 0.990 [0.983-0.998], p = .011). Overall survival was similar in mild hemodialysis access-induced distal ischemia and controls (2-year, 79% ±5; 4-year, 57% ±6, p = .818). In contrast, 4-year survival was >20% lower in patients with severe hemodialysis access-induced distal ischemia (2-year 62%± 10; 4-year 34% ± 10; p = .026). CONCLUSION Presence of severe hemodialysis access-induced distal ischemia may be associated with poorer survival in hemodialysis patients. Lower digital brachial index values are associated with higher overall mortality, even following correction for other known risk factors.
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Affiliation(s)
| | - Reshabh Yadav
- Department of Surgery, Máxima MC, Veldhoven, The Netherlands
| | - Rosanne Wouda
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
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Yadav R, Gerrickens MWM, Teijink JAW, Scheltinga MRM. Abnormal digital brachial index prior to hemodialysis access construction and cardiovascular mortality. Hemodial Int 2020; 24:335-343. [DOI: 10.1111/hdi.12835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 03/27/2020] [Accepted: 04/16/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Reshabh Yadav
- Department of Surgery Máxima Medical Center Veldhoven The Netherlands
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Gerrickens MW, Vaes RH, Wiersma V, van Kuijk SM, Snoeijs MG, Govaert B, Scheltinga MR. Revision using distal inflow for high flow hemodialysis access alters arterial flow characteristics in the dialysis arm. J Vasc Surg 2020; 71:920-928. [DOI: 10.1016/j.jvs.2019.06.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/19/2019] [Indexed: 12/11/2022]
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Beathard GA, Jennings WC, Wasse H, Shenoy S, Hentschel DM, Abreo K, Urbanes A, Nassar G, Dolmatch B, Davidson I, Asif A. ASDIN white paper: Assessment and management of hemodialysis access-induced distal ischemia by interventional nephrologists. J Vasc Access 2019; 21:543-553. [PMID: 31884872 DOI: 10.1177/1129729819894774] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Although not common, hemodialysis access-induced distal ischemia is a serious condition resulting in significant hemodialysis patient morbidity. Patients with signs and symptoms suggestive of hand ischemia frequently present to the general and interventional nephrologist for evaluation. In order to care for these cases, it is necessary to understand this syndrome and its management. Most cases can be managed conservatively without intervention. Some cases requiring intervention may be treated using techniques within the scope of practice of the interventional nephrologists while other cases require vascular surgery. In order for the interventional nephrologists to evaluate and manage these cases in a timely and appropriate manner, practice guidelines are presented.
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Affiliation(s)
| | - William C Jennings
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | | | - Surendra Shenoy
- Barnes-Jewish Hospital, Washington University, St. Louis, MO, USA
| | | | - Kenneth Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Aris Urbanes
- Internal Medicine, Wayne State University, Detroit, MI, USA
| | - George Nassar
- Weill Cornell Medicine, New York, NY, USA
- Houston Methodist Hospital, Houston, TX, USA
| | | | - Ingemar Davidson
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Arif Asif
- Hackensack Meridian School of Medicine at Seton Hall University, Nutley, NJ, USA
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Kordzadeh A, Parsa AD. A systematic review of distal revascularization and interval ligation for the treatment of vascular access-induced ischemia. J Vasc Surg 2019; 70:1364-1373. [PMID: 31153703 DOI: 10.1016/j.jvs.2019.02.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 02/05/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vascular access-induced ischemia remains a rare but significant complication of arteriovenous fistulas. Distal revascularization and interval ligation (DRIL) is one form of treatment. However, its collated efficacy through a systematic review is yet to be established. METHODS An electronic and systematic search of the literature in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Library from 1966 to 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. Quality assessment of the articles was performed using the Oxford Critical Appraisal Skills Programme, and the recommendation for practice was examined through the National Institute for Health and Care Excellence. Data of treated cases, success, time to ischemia, follow-up, age, sex, diabetes mellitus, fistula type, conduit type, and grade of ischemia were extracted and subjected to a pooled variance-weighted random-effects model. RESULTS Twenty-two studies (n = 459 individuals) were subjected to DRIL. Time to ischemia was 196 days (interquartile range, 30-600 days). Ischemia grade 3/4 (52%) was the most common presentation. The overall success (grades 1-4) was 81% (95% confidence interval, 80.9%-82.5%) during a mean and median follow-up of 22.2 months (interquartile range, 1-60 months) and 18 months, respectively. The conduit of choice was the great saphenous vein (n = 300/459 [65%]), and bypass thrombosis was highest in the polytetrafluoroethylene group (n = 19/44 [43%]). CONCLUSIONS DRIL with adequate long-term outcomes is an effective technique for the treatment of vascular access-induced ischemia.
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Affiliation(s)
- Ali Kordzadeh
- Department of Vascular, Endovascular and Renal Access, Broomfield Hospital, Mid Essex Hospital Service NHS Trust, Essex, United Kingdom; Faculty of Medical Sciences, Anglia Ruskin University, Cambridge, United Kingdom.
| | - Ali Davod Parsa
- Faculty of Medical Sciences, Anglia Ruskin University, Cambridge, United Kingdom
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Gerrickens MW, Vaes RH, Govaert B, van Loon M, Tordoir JH, van Hoek F, Teijink JA, Scheltinga MR. Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula. Eur J Vasc Endovasc Surg 2018; 55:874-881. [DOI: 10.1016/j.ejvs.2018.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/10/2018] [Indexed: 10/17/2022]
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Gerrickens MWM, Vaes RHD, Govaert B, Teijink JAW, Scheltinga MR. Basilic vein transposition for unsuitable upper arm hemodialysis needle access segment may attenuate concurrent hand ischemia. Hemodial Int 2018. [DOI: 10.1111/hdi.12654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | - Roel H. D. Vaes
- Department of Surgery; Máxima Medical Centre; Veldhoven The Netherlands
| | - Bastiaan Govaert
- Department of Surgery; Máxima Medical Centre; Veldhoven The Netherlands
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Atomura D, Aihara J, Omori M, Terashi H. Utility of perioperative skin perfusion pressure measurement for treatment of ulcers caused by arteriovenous access ischaemic steal. Int Wound J 2018; 15:454-459. [PMID: 29356404 DOI: 10.1111/iwj.12886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/28/2017] [Accepted: 12/04/2017] [Indexed: 11/28/2022] Open
Abstract
Arteriovenous access ischaemic steal is a serious complication following arteriovenous fistula (AVF) construction. The aim of treatment is to improve distal circulation without impairing the function of the fistula. Therefore, any repair should be performed with intraoperative monitoring. We report 2 cases of this disorder treated using perioperative measurement of skin perfusion pressure (SPP) for preoperative surgical planning and intraoperative guidance. A 73-year-old woman with a left cubital AVF developed gangrene of the tip of the left little finger. Arteriovenous access ischaemic steal was suspected. The SPP of the little finger was 18 mm Hg, which increased to 65 mm Hg after manual occlusion of the fistula. A 58-year-old woman with a left antebrachial AVF had gangrene of the tip of the left middle finger. The SPP was 19 mm Hg, and steal syndrome was suspected based on angiography and the SPP with manual occlusion of the fistula. In both cases, serial plication of the fistula was performed based on intraoperative perfusion pressure monitoring, leading to the successful resolution of the ischaemic steal syndrome. In both cases, haemodialysis could be continued through the repaired fistula.
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Affiliation(s)
- Daisuke Atomura
- Department of Plastic Surgery, Kawasaki Hospital, Kobe, Japan
| | - Junko Aihara
- Department of Plastic Surgery, Kawasaki Hospital, Kobe, Japan
| | - Makoto Omori
- Department of Plastic Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Hiroto Terashi
- Department of Plastic and Reconstructive Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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12
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Proximal radial artery arteriovenous fistula for hemodialysis vascular access. J Vasc Surg 2018; 67:244-253. [DOI: 10.1016/j.jvs.2017.06.114] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/23/2017] [Indexed: 11/20/2022]
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Abstract
Purpose The aim of this study is to validate the current applicability of arteriovenous access banding in high flow access (HFA) and/or haemodialysis access-induced distal ischaemia (HAIDI). Methods This retrospective study was conducted at the GEV (Grupo de Estudos Vasculares) vascular access centre. The clinical records of consecutive patients undergoing banding for HAIDI and HFA symptoms, between June 2011 and January 2015, were reviewed until April 2015. All vascular access patients’ consultation records and surgical notes were reviewed. We analysed and compared patients’ age, gender, comorbidities, symptoms and intraoperative ultrasound control. We defined technical failure as recurrence of symptoms, requiring new banding. Excessive banding, access thrombosis, rupture and false aneurysm development were registered as complications. Primary clinical success was defined as improvement of symptoms or effective flow reduction after banding, with no need for reintervention. If one reintervention was necessary, we have defined it as secondary clinical success. Results Overall, 119 patients underwent banding: 64 (54%) with HAIDI and 55 (46%) with HFA. The HAIDI group was significantly older (65 ± 13 years compared with 56 ± 22 years, p = 0.001) and had significantly greater number of patients with diabetes (56% vs 24%, p = 0.004). Primary success was achieved in 85 patients (71.4%) and the secondary success rate was 84.9%. Older age (p = 0.016) and intraoperative ultrasound control (p = 0.012) were significantly associated with primary success. Conclusions Our results do not corroborate the high incidence of thrombosis previously reported as associated with AV access banding and suggest that ultrasound control is crucial for preventing technical failure. The procedure was effective on both compared groups.
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