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Mendes D, Almeida P, Sousa C, Loureiro L, Teixeira S, Rego D, Norton-de-Matos A. Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques. Ann Vasc Surg 2023:S0890-5096(23)00128-0. [PMID: 36868458 DOI: 10.1016/j.avsg.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/14/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques. METHODS Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2 years. RESULTS Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64 ± 15 years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5 months (12-216 months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1 year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2 years, with a median follow-up of 19 months (6-92 months). CONCLUSIONS AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.
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Affiliation(s)
- Daniel Mendes
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal; ICBAS-School of Medicine and Biomedical Sciences, University of Porto (ICBAS-UP), Porto, Portugal.
| | - Paulo Almeida
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Clemente Sousa
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal; Nursing School of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Luís Loureiro
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal; ICBAS-School of Medicine and Biomedical Sciences, University of Porto (ICBAS-UP), Porto, Portugal
| | - Sérgio Teixeira
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal; ICBAS-School of Medicine and Biomedical Sciences, University of Porto (ICBAS-UP), Porto, Portugal
| | - Duarte Rego
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Costa LL, de Matos AN, Almeida P, Teles P, Loureiro L, Campos L, Delgado E, Oliveira D, Campos T, Inácio M, Fernandes F, Coutinho S, Ventura A, Pereira S, Castro A, Xavier E, Sousa CN. Radio-cephalic fistula recovered with drainage to median basilic vein by straightening of the forearm cephalic vein: A case report. Semin Dial 2022; 35:544-547. [PMID: 35608251 DOI: 10.1111/sdi.13096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
The distal arteriovenous fistula (AVF) has less complications and better patency than the proximal fistula, when it works properly. The complications of outflow of the fistula are complex, and it is necessary to analyze all solutions to solve the problem. We introduce a novel approach to solve outflow problems of a radio-cephalic AVF by straightening of the forearm cephalic vein with drainage into the median basilic vein.
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Affiliation(s)
- Luísa Lemos Costa
- Nephrology Department, Centro Hospitalar Viseu e Tondela, Viseu, Portugal.,Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal
| | | | - Paulo Almeida
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal.,Angiology and Vascular Surgery Departament, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Paulo Teles
- School of Economics and LIAAD-INESC Porto LA, Porto University, Porto, Portugal
| | - Luís Loureiro
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal.,Angiology and Vascular Surgery Departament, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | | | | | | | | | | | | | | | | | - Ana Castro
- S Francisco Dialysis Unit, Porto, Portugal
| | - Eva Xavier
- S Francisco Dialysis Unit, Porto, Portugal
| | - Clemente Neves Sousa
- Vascular Access Center (Grupo Estudos Vasculares-GEV), Porto, Portugal.,S Francisco Dialysis Unit, Porto, Portugal.,Nursing School of Porto, Porto, Portugal.,Faculty of Medicine, CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal
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3
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Sousa CN, Cabrita F, Rodrigues S, Ventura A, Norton de Matos A, Almeida P, Teles P, Loureiro L, Xavier E. Radial-cephalic fistula recovered with graft interposition from the brachial artery into the cephalic vein-Patient with two arteriovenous fistulas. Ther Apher Dial 2020; 24:731-735. [PMID: 32090460 DOI: 10.1111/1744-9987.13487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/23/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Clemente Neves Sousa
- S. Francisco Dialysis Unit, Porto, Portugal.,Vascular Access Center (Grupo Estudos Vasculares), Porto, Portugal.,Nursing School of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, Porto University, Porto, Portugal
| | - Filipa Cabrita
- B. Braun Avitum, Renal Care Center Senhora da Hora, Porto, Portugal
| | - Sara Rodrigues
- B. Braun Avitum, Renal Care Center Senhora da Hora, Porto, Portugal
| | - Ana Ventura
- S. Francisco Dialysis Unit, Porto, Portugal.,Nephrology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | | | - Paulo Almeida
- Vascular Access Center (Grupo Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Paulo Teles
- School of Economics and LIAAD-INESC Porto LA, University of Porto, Porto, Portugal
| | - Luís Loureiro
- Vascular Access Center (Grupo Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Eva Xavier
- S. Francisco Dialysis Unit, Porto, Portugal
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Pirozzi N, De Alexandris L, Fazzari L, Scrivano J, Pirozzi R, Menè P. Cubital vein transposition for a distal radiocephalic fistula complicated by outflow obstruction. J Vasc Access 2019; 21:520-523. [DOI: 10.1177/1129729819890472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Outflow stenosis is a frequent complication of vascular access for hemodialysis. It may cause increased pressure within the angioaccess along with reduced blood flow. Elective treatment is percutaneous transluminal angioplasty; however, when a long occlusion (>2 cm) occurs, success and mid-term patency of endovascular treatment are uncertain. We describe a case series of patients with long occlusion of elbow outflow complicating an otherwise excellent forearm arteriovenous fistula, treated by a bypass across the elbow through cubital vein transposition. Patients and methods: Six consecutive patients have been treated between 2015 and 2017; all were referred because of either low flow, increased venous pressure, excessive bleeding time, or recirculation and were examined by duplex ultrasound. A total of 83% of patients showed associated thrombosis within the access. All procedures were performed under loco-regional anesthesia and preventive hemostasis. Surgical thrombectomy was also performed when needed. Results: Immediate success was obtained in all but two patients converted in veno-venous polytetrafluoroethylene bypass. Post-operative blood flow increased from 316 to 878 mL/min. All patients were dialyzed through the forearm access immediately the day after surgery, without the need for central vein catheter. Overall, 75% of patients needed a percutaneous transluminal angioplasty of the veno-venous anastomosis within 6 months. Primary and secondary patency at 12 and 24 months were 25%–0% and 100%–100%, respectively. Conclusion: Outflow reconstruction through the elbow bypass by cubital vein transposition is a valuable resource to rescue radiocephalic arteriovenous fistula complicated by outflow obstruction, avoiding the use of an interim central vein catheter. Endovascular treatment is vital to maintain functional patency in the mid- and long term.
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Affiliation(s)
- Nicola Pirozzi
- Nephrology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Lorenzo De Alexandris
- Nephrology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | | | | | - Paolo Menè
- Nephrology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Norton de Matos A, Sousa CN, Almeida P, Teles P, Rego D, Teixeira G, Loureiro L, Teixeira S, Antunes I. Radiocephalic Fistula Recovery Using the Brachial Vein and Forearm Basilic Vein: A Case Series and Literature Review. Ther Apher Dial 2018; 22:570-574. [PMID: 30047255 DOI: 10.1111/1744-9987.12719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/15/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022]
Abstract
Vascular access dysfunction is a serious problem in dialysis units. Some patients have complex dysfunctions that are difficult to resolve. In this article, we report the case a of two patients with radiocephalic arteriovenous fistulae (RC-AVF) who had stenosis/occlusion of the forearm median vein and where we used the basilic vein of the forearm as a solution. We reviewed the use of this surgical solution in RC-AVF. Two male patients on hemodialysis exhibited stenosis/occlusion of the forearm median vein. The forearm basilic vein was isolated and rotated toward the forearm median vein in order to solve RC-AVF problems. One patient had fistula thrombosis 5 months after the procedure, while for the other patient, the fistula continues to work without problems. Literature describes only a few cases using the forearm basilic vein or the brachial vein for fistula recovery. This procedure increased the patency of fistulas. This approach has been proven to be a good solution for solving outflow problems using the superficial or deep veins, increasing fistula patency and avoiding the need to place a central venous catheter and all the related complications.
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Affiliation(s)
- António Norton de Matos
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Clemente N Sousa
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Nursing School of Porto, Porto, Portugal.,CINTESIS-Center for Health Technology and Services Research Faculty of Medicine, Porto University, Porto, Portugal
| | - Paulo Almeida
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Paulo Teles
- School of Economics and LIAAD-INESC Porto LA, University of Porto, Porto, Portugal
| | - Duarte Rego
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Gabriela Teixeira
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Luís Loureiro
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Sérgio Teixeira
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Inês Antunes
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
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Norton de Matos A, Sousa CN, Almeida P, Teles P, Rego D, Teixeira G, Loureiro L, Teixeira S. Radio-cephalic arteriovenous fistula recovered with drainage through the brachial vein. Hemodial Int 2018; 22:E53-E56. [PMID: 29461007 DOI: 10.1111/hdi.12641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Indexed: 11/27/2022]
Abstract
Dysfunction of arteriovenous access for hemodialysis is a challenge for the vascular surgeon. Some patients have complex vascular access with problems that are difficult to solve. Careful analysis of the vascular network with ultrasound and dissection of the veins during surgery can help to identify the best option for each access. We introduce and discuss the case of creation of a radio-cephalic fistula with outflow into the brachial vein in 64-year-old hemodialysis male patient. This technique enables extending fistula patency, arterializing the brachial vein, and improves cost efficiency.
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Affiliation(s)
- António Norton de Matos
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Clemente Neves Sousa
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Nursing School of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research Faculty of Medicine, Porto, Portugal
| | - Paulo Almeida
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Paulo Teles
- School of Economics and LIAAD-INESC Porto LA, Porto University, Porto, Portugal
| | - Duarte Rego
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Gabriela Teixeira
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Luís Loureiro
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Sérgio Teixeira
- Vascular Access Center (Grupo de Estudos Vasculares), Porto, Portugal.,Angiology and Vascular Surgery Department, Centro Hospitalar do Porto, Porto, Portugal
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