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Pourriyahi H, Pourriahi H, Najd Sepas H. Salvage Aneurysmorrhaphy as an Adaptable and Still Pertinent Technique in the Management of Challenging True Aneurysms of Arteriovenous Fistulas: A Case Series of Different Variations, With Illustrative Surgical Pictures. EJVES Vasc Forum 2024; 61:126-131. [PMID: 38884071 PMCID: PMC11177082 DOI: 10.1016/j.ejvsvf.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/04/2024] [Accepted: 05/02/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Aneurysmorrhaphy, described as reduction aneurysmoplasty, partial aneurysmectomy, or vessel wall recalibration, can be considered a suitable surgical plan for true aneurysms of arteriovenous fistulas (AVFs), allowing for a dynamic approach to reconstruction of aneurysmal AVFs of different severities, ensuring salvage of the native access. Report Six challenging cases of AVF aneurysms are presented, some with extremely dilated and tortuous megafistulas, for which three surgical technique variations were performed. The patients had a mean age of 59.2 years, 50% were female, with brachiocephalic (n = 5, 83.3%) or brachiobasilic (n = 1, 16.7%) AVFs. The fistulas were created an average of 4.67 years previously, and the aneurysms had an average maximum diameter of 37.5 mm (range 25-60 mm). Surgical indications were rupture risk, thrombosis, or outflow stenosis compromising haemodialysis, infections, and concerns for quality of life (affected by post-puncture bleedings, disfiguring aesthetics, pain, and discomfort). The surgical techniques were simple aneurysmorrhaphy (n = 3, 50%), aneurysmorrhaphy with partial excision of aneurysmal segment with end to end anastomosis of venous ends (n = 2, 33.3%), and aneurysmorrhaphy with establishment of new venous outflow (n = 1, 16.7%). All AVFs were patent post-operatively and at follow up (mean 5.6 months, median one month). Haemodialysis was resumed through the AVFs at a mean of 2.17 weeks post-operatively, with placement of an alternative route for haemodialysis in the meantime. No patients experienced post-operative complications. Discussion Experience with the more challenging cases shows that aneurysmorrhaphy can still be considered an acceptable, flexible, and pertinent method for salvage of megafistulas, giving the surgeon the much needed versatility to adapt to anatomical and pathological variations, with high patency rates and minimal complications, especially when other treatment options are not possible in complicated cases. AVF salvage through aneurysmorrhaphy allows for a dynamic approach to the reconstruction of severely tortuous, dilated veins, ensuring patency of the native AVF.
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Affiliation(s)
- Homa Pourriyahi
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Hossein Najd Sepas
- Department of Vascular Surgery, Rasool-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Tong X, Ran Y, Da J, Hu Y, Yuan J, Rui Y. Internal fistula stenosis with true pseudoaneurysm formation in a patient on maintenance hemodialysis: A case report. Medicine (Baltimore) 2024; 103:e38111. [PMID: 38728493 PMCID: PMC11081536 DOI: 10.1097/md.0000000000038111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Arteriovenous fistula stenosis can directly lead to the formation of autologous arteriovenous fistula aneurysms (AVFAs), but the coexistence of true and pseudoaneurysms is relatively rare. The coexistence of true and pseudoaneurysms increases the risk of rupture of the arteriovenous fistula and complicates subsequent surgical intervention, potentially posing a threat to the patient's life, and thus requires significant attention. CASE PRESENTATION The patient presented with arteriovenous fistula (AVF) after hemodialysis 6 years ago. 2 years ago, the patient presented with a mass that had formed near the left forearm arteriovenous fistula and gradually increased in size. Preoperatively, the AVF stenosis was identified as the cause of the mass formation, and the patient was operated on. First, the blood flow was controlled to reduce the pressure at the aneurysm, and then the incision was enlarged to separate the AVF anastomosis from the mass area. The stenotic segment of the true and pseudo aneurysms and cephalic vein was removed and the over-dilated proximal cephalic vein was locally narrowed and subsequently anastomosed with the proximal radial artery to create AVF. The patient was dialyzed with an internal fistula the next day and showed no clinical manifestations related to end-limb ischemia. CONCLUSION We removed a true pseudoaneurysm in AVF and secured the patient's vascular access. This report provides an effective strategy to manage this condition.
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Affiliation(s)
- Xiaoya Tong
- College of Clinical Medicine, Guizhou Medical University, Guiyang, China
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
- Guizhou Provincial Institute of Nephritic and Urinary Disease, Guiyang, Guizhou, China
| | - Yan Ran
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
- Guizhou Provincial Institute of Nephritic and Urinary Disease, Guiyang, Guizhou, China
| | - Jingjing Da
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
- Guizhou Provincial Institute of Nephritic and Urinary Disease, Guiyang, Guizhou, China
| | - Ying Hu
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
- Guizhou Provincial Institute of Nephritic and Urinary Disease, Guiyang, Guizhou, China
| | - Jing Yuan
- Department of Nephrology, People’s Hospital of Guizhou Province, Guiyang, China
- Guizhou Provincial Institute of Nephritic and Urinary Disease, Guiyang, Guizhou, China
| | - Yan Rui
- College of Clinical Medicine, Guizhou Medical University, Guiyang, China
- Department of Nephrology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Abstract
Many end-stage kidney failure patients require hemodialysis as a life-sustaining treatment. Hemodialysis access via arteriovenous fistula or graft creation is preferred over long-term dialysis catheters, but intervention to maintain patency and prevent access failure is common. Endovascular and open surgical techniques are both utilized to address the underlying etiology of failure. Endovascular options include balloon angioplasty, angioplasty with stenting, and drug-eluting stents. Open revision is commonly needed for recurrent stenosis, aneurysmal or pseudoaneurysmal change, hemodialysis access-induced distal ischemia, and infection. Treatment plans should be guided by patient's individualized goals of care and require a multidisciplinary approach to the management of this complex disease.
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Affiliation(s)
- John Iguidbashian
- Department of Surgery, University of Colorado Anschutz School of Medicine, 457 South Kingston Cir, Aurora, CO 80012, USA
| | - Rabbia Imran
- University of Colorado Anschutz School of Medicine, 13001 East 17th Place, Aurora, CO 80045, USA
| | - Jeniann A Yi
- Department of Surgery, University of Colorado Anschutz School of Medicine, 457 South Kingston Cir, Aurora, CO 80012, USA.
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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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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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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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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 925] [Impact Index Per Article: 231.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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García-Medina J, Maldonado-Cárceles AB, García-Alfonso JJ, Árense-Gonzalo JJ, Torres-Cantero AM. Stent graft deployment in haemodialysis fistula: patency rates in partially thrombosed aneurysm and residual thrombi. Clin Kidney J 2020; 14:814-819. [PMID: 33777364 PMCID: PMC7986443 DOI: 10.1093/ckj/sfz193] [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: 07/18/2019] [Accepted: 12/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background Current evidence is insufficient to determine the contribution of stent grafts as treatment in partially thrombosed aneurysms or residual wall-adherent thrombi in arteriovenous fistulae (AVFs) for haemodialysis. The overall purpose of this study was to analyse patency rates of post-interventional covered stent deployment in those cases. We also assessed if patency rates differed when fistulas were punctured through the stent during dialysis sessions. Methods We conducted a retrospective study between 2006 and 2014 analysing post-intervention primary patency rates using the Kaplan-Meier log-rank test. Multivariate Cox proportional regression models were performed to determine if cannulation within the stent graft area was a potential risk factor for occlusion, by adjusted hazard ratio (HR). Results A total of 27 procedures were included in the study. Primary patency rates (%) after stent deployment at 3, 6, 12, 24, 36 and 72 months were, respectively: total 59, 32, 32, 21, 11 and 5; stent puncture 53, 21, 21, 16, 5 and 0; and no stent puncture 80, 80, 80, 40, 40 and 40. Cannulation through the stent graft was not significantly associated with increased risk of obstruction in multivariate analysis (HR = 3.01; P = 0.286). Conclusion Stent graft treatment may be a feasible procedure in partially thrombosed aneurysms and residual thrombi in AVF. Although fistulas punctured through the stent presented lower patency rates, this practice was not associated with a higher risk of obstruction. Giving the impossibility of comparing with similar approaches, further studies are needed to confirm or refute the advantages of this procedure.
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Affiliation(s)
- José García-Medina
- Department of Vascular and Interventional Radiology, General University Hospital "Reina Sofia", Murcia, Spain
| | - Ana B Maldonado-Cárceles
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, Murcia, Spain.,Department of Preventive Medicine, General University Hospital "Reina Sofia", Murcia, Spain
| | - Juan J García-Alfonso
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, Murcia, Spain
| | - Julián J Árense-Gonzalo
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, Murcia, Spain
| | - Alberto M Torres-Cantero
- Division of Preventive Medicine and Public Health, University of Murcia School of Medicine, Murcia, Spain.,Department of Preventive Medicine, University Hospital "Virgen de la Arrixaca", Murcia, Spain
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Wang S, Wang MS. Intraoperative pneumatic tourniquet use may improve the clinical outcomes of arteriovenous fistula creations. J Vasc Access 2019; 20:706-715. [PMID: 31081478 DOI: 10.1177/1129729819845968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES A major pathology affecting the usability of arteriovenous fistulas for hemodialysis is juxta-anastomosis stenosis. Intraoperative pneumatic tourniquet eliminates the use of vascular clamps, reduces vascular trauma, and may then reduce the juxta-anastomosis stenosis. The aim of this study was to compare the outcomes of arteriovenous fistula creations using the tourniquet-assisted approach versus the clamp-assisted approach. METHODS This retrospective study analyzed the outcomes of primary arteriovenous fistulas created by the lead author from 2008 to 2017 and met the specified inclusion criteria applied to both groups. RESULTS A total of 575 patients were included. Upon comparing the tourniquet group (n = 411) with the clamp group (n = 164): the primary arteriovenous fistula failure rate was significantly lower (2.4% vs 7.3%, p = 0.01); the percentage of arteriovenous fistula used for hemodialysis without initial interventions was significantly higher (71.5% vs 45.1%, p < 0.001) and with initial interventions was conversely lower (26.0% vs 47.6%, p < 0.001); the primary patency rate of the whole fistula conduits was significantly higher (44.2% vs 23.0% at 1 year, p < 0.001) and so was the cumulative patency rate (97.2% vs 92.6% at 1 year, p < 0.001); and the juxta-anastomosis primary patency rate (free of interventions for the juxta-anastomosis region) was higher (71.0% vs 47.8% at 1 year, p < 0.001). Based on multivariate Cox proportional hazards regression analyses, the effect of tourniquet use on the juxta-anastomosis primary patency remained significant (hazard ratio = 2.24, 95% confidence interval = 1.72-2.93, p < 0.001) when other significant factors (fistula location, gender, and diabetes) were considered. CONCLUSION Intraoperative pneumatic tourniquet may significantly improve the clinical outcomes of arteriovenous fistula creations by reducing juxta-anastomosis trauma and subsequent stenosis.
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Affiliation(s)
- Shouwen Wang
- Ambulatory Surgery Center, Arizona Kidney Disease & Hypertension Center (AKDHC), Phoenix, AZ, USA
| | - Michele S Wang
- Ambulatory Surgery Center, Arizona Kidney Disease & Hypertension Center (AKDHC), Phoenix, AZ, USA
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Wan Z, Lai Q, Zhou Y, Chen L, Tu B. Partial aneurysmectomy for treatment of autologous hemodialysis fistula aneurysm is safe and effective. J Vasc Surg 2019; 70:547-553. [PMID: 30850291 DOI: 10.1016/j.jvs.2018.10.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/17/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the outcome and the factors associated with stenosis after treatment using partial aneurysmectomy for aneurysm in autologous arteriovenous fistulas. METHODS This retrospective cohort study was conducted from July 2007 to June 2016 and included patients with complicated aneurysms in upper extremity autologous arteriovenous fistulas were treated by partial aneurysmectomy. Vascular ultrasound examination was performed every 6 months after the surgery. RESULTS Forty-one patients (median age, 37 years; 70.7% males) were included. Of the patients, 95.1% had a radial-cephalic fistula in the forearm and nearly 88% had 1 or 2 aneurysms in arteriovenous fistulas that had been created for 10 to 84 months. Technical success of partial aneurysmectomy was achieved in all patients. The access diameter (44.0 ± 5.1 mm vs 10.4 ± 1.8 mm; P < .01) and brachial artery blood flow (1618.2 ± 277.0 mL/min vs 772.1 ± 127.4 mL/min; P < .01) were significantly decreased after the surgery. The median follow-up time was 27 months (range, 12-43 months). The primary patency rates at 6 and 12 months were 100% and 95%, respectively. Loss of patency was due to stenosis of the remodeled fistulas, which occurred in seven patients (17%). Multivariate COX regression analysis revealed that diabetes (hazard ratio, 114.28; 95% confidence interval, 2.85-4583.94; P = .01) was a risk factor for the impaired primary patency rates. A larger postprocedure residual diameter trended to favor fistula patency (hazard ratio, 0.46; P = .07). Stenosis was successfully treated with percutaneous transluminal angioplasty. CONCLUSIONS Partial aneurysmectomy is an effective and safe method for treating aneurysm of upper extremity autologous arteriovenous fistulas, leading to good 12-month primary patency and no aneurysm recurrence. Using a larger catheter to size the revised fistula during aneurysmectomy may increase access patency.
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Affiliation(s)
- Ziming Wan
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiquan Lai
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhou
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liqun Chen
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tu
- Department of Ultrasonography, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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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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