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Allam AK, Salem AA, Ibrahim SG, Abd Elsamea AM, Afifi HS. Straight lateral thigh femoropopliteal-femoral arteriovenous graft an alternative vascular access for patients with exhausted upper limbs dialysis access. J Vasc Access 2024; 25:854-862. [PMID: 36447353 DOI: 10.1177/11297298221139060] [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
INTRODUCTION The durability of hemodialysis vascular access remains a troublesome issue for the patients as well as vascular surgeons that requires frequent reinterventions to maintain the access function. AIM This study aimed to evaluate straight thigh polytetrafluethylene (PTFE) arteriovenous graft (AVG) in patients with exhausted upper extremities dialysis access. METHOD Our study was a retrospective analysis of prospectively collected data of 30 patients were operated upon for straight pattern lateral thigh PTFE AVG between 2016 and 2018. The primary outcome was efficacy and patency of AVG, and secondary outcome was procedure safety, including infection, thrombosis, ligation, lower limb functional status, and mortality. RESULTS A 30 patients with 30 Lower Limb AVG with maximum 30-month follow-up period. The mean age was 48 years. Males were (n = 15/30). Thrombophilia patients were (n = 7/30). Primary patency at 6 months was 100%. It declined to 93% at 12 months, 73% at 18 months, 47% at 24 months, and 40% at 30 months. The secondary patency was 97% at 18 months, 83% at 24 months, and 73% at 30 months. More than half of the patients showed complications (n = 18/30), the most frequent was thrombosis (n = 16/18). A secondary procedure was needed for 17 patients, the most frequent was thrombectomy (n = 11/17), adjunctive culprit lesion repair was the key for regaining graft patency. Graft removal was necessary in six patients due to infection (n = 4) and ruptured graft aneurysm (n = 2). CONCLUSION Lateral straight thigh PTFE AVG is a reliable and durable alternative modality with adequate dialysis efficacy in patients with exhausted upper extremities dialysis accesses. Secondary procedures due to complications were frequent but no significant major bleeding as regard patients with ruptured graft were non-significant and no distal threatening ischemia or related deaths were observed.
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Affiliation(s)
- Ahmed K Allam
- General Surgery Department, Benha University Hospitals, Benha, Egypt
| | - Atef A Salem
- General Surgery Department, Benha University Hospitals, Benha, Egypt
| | - Samia G Ibrahim
- General Surgery Department, Benha University Hospitals, Benha, Egypt
| | | | - Haitham S Afifi
- General Surgery Department, Benha University Hospitals, Benha, Egypt
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Zhang R, Zhang J, Xue X, Sun Z, Du N, Chen N, Dong F, Wang X, Tian Q. Comparison of Lower and Upper Extremity Arteriovenous Graft: A Retrospective Clinical Analysis with 5-Year Follow-Up. Ann Vasc Surg 2024; 98:235-243. [PMID: 37392856 DOI: 10.1016/j.avsg.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/05/2023] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND For patients in whom an upper extremity (UE) vascular access cannot be established, the lower extremity (LE) arteriovenous graft (AVG) could be selected. However, the application of LE AVG is limited owing to its high infection rate, uncertain patency time, and technical difficulties. This study aimed to compare the long-term patency rates and the incidence of vascular access complications of AVG in the LE and UE to provide a reference for the applications of AVG, especially in the LEs. METHODS This was a retrospective analysis of patients who successfully underwent LE or UE AVG placement from March 2016 to October 2021. Patient characteristics were collected and compared using parameter or nonparameter tests according to data type. Postoperative patency was evaluated using Kaplan-Meier test. Postoperative complication incidence density and intergroup comparison were estimated using the Poisson distribution. RESULTS Twenty-two patients with LE AVG and 120 patients with UE AVG were included. The 1-year primary patency rate was 67.4% (±11.0% standard error [SE]) in the LE group and 30.1% (±4.5% SE) in the UE group (P = 0.031). The assisted primary patency rate at postoperative months 12, 24, and 36 was respectively 78.6% (±9.6% SE), 65.5% (±14.4% SE), and 49.1% (±17.8% SE) in the LE group and 63.3% (±4.6% SE), 47.5% (±5.4% SE), and 30.4% (±6.1% SE) in the UE group (P = 0.137). The secondary patency rate at postoperative months 12, 24, and 36 remains 95.5% (±4.4% SE) in the LE group and 89.3% (±2.9% SE), 83.7% (±3.9% SE), and 73.0% (±6.2% SE), respectively, in the UE group (P = 0.200). Postoperative complications included stenosis, occlusion/thrombosis, infection, steal syndrome, pseudoaneurysm, severe postoperative serum swelling, and AVG exposure. The total incidence rates of postoperative complications were 0.87 (95% confidence interval [CI] 0.59-1.23) versus 1.61 (95% CI 1.45-1.79) (P = 0.001) cases/person-year, the incidence rates of stenosis were 0.45 (95% CI 0.26-0.73) versus 0.92 (95% CI 0.80-1.06) (P = 0.005) cases/person-year and the incidence rates of occlusion/thrombosis were 0.34 (95% CI 0.17-0.59) versus 0.62 (95% CI 0.52-0.74) cases/person-year in the LE group compared to those in the UE group (P = 0.041). CONCLUSIONS LE AVG had higher primary patency rate and lower postoperative complication incidence than UE AVG. With the development of interventional technology, both LE AVG and UE AVG exhibited high secondary patency rates. LE AVG can be a reliable and long-term alternative for appropriately selected patients with unusable UE vessels.
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Affiliation(s)
- Ruibin Zhang
- Department of Nephrology, Blood Purification Center, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Zhang
- Department of Nephrology, Heze Municipal Hospital, Heze, Shandong, China
| | - Xia Xue
- Department of General Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhenfu Sun
- Department of Nephrology, Heze Municipal Hospital, Heze, Shandong, China
| | - Nannan Du
- Department of Nephrology, Blood Purification Center, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Nan Chen
- Department of Nephrology, Heze Municipal Hospital, Heze, Shandong, China
| | - Fangfang Dong
- Department of Nephrology, Gaomi People's Hospital, Gaomi, Shandong, China
| | - Xiaoping Wang
- Department of Nephrology, Blood Purification Center, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
| | - Qiuju Tian
- Department of Nephrology, Heze Municipal Hospital, Heze, Shandong, China.
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Sekhar R, Patkar A, Singh S, Kalwadia N, Gadhavi R. Lower limb dialysis grafts: Are they really that bad? INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_41_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access. J Vasc Surg 2021; 74:225-229. [PMID: 33348002 DOI: 10.1016/j.jvs.2020.12.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/05/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency. METHODS Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed. RESULTS A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications. CONCLUSIONS Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.
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Kingsmore DB, Stevenson KS, Jackson A, Desai SS, Thompson P, Karydis N, Franchin M, White B, Tozzi M, Isaak A. Arteriovenous Access Graft Infection: Standards of Reporting and Implications for Comparative Data Analysis. Ann Vasc Surg 2020; 63:391-398. [DOI: 10.1016/j.avsg.2019.08.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 11/28/2022]
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Agrawal N, Garg N, Adapa S, Cardarelli F. Kidney allograft dysfunction due to ipsilateral thigh arteriovenous graft. J Vasc Access 2019; 21:783-784. [DOI: 10.1177/1129729819877320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Arteriovenous graft in the thigh is used not infrequently for hemodialysis. Outcomes with this lower extremity dialysis access are generally comparable to upper extremity access and superior to long-term catheter use. However, it could have significant implications in a patient getting a kidney transplant. Here we describe a case of thigh arteriovenous graft causing kidney allograft dysfunction in a new transplant recipient, and this resolved with graft ligation.
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Affiliation(s)
| | - Neetika Garg
- University of Wisconsin–Madison, Madison, WI, USA
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McEwan SJ, Maple H, Gibbs PJ. Good long-term patency: 10-year follow-up using the mid-thigh adductor loop arteriovenous graft. J Vasc Access 2018; 20:313-320. [DOI: 10.1177/1129729818805955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Definitive access in patients requiring renal replacement therapy is an ever-increasing challenge. For those where autogenous venous access is no longer a viable option, arteriovenous grafts can be considered. This article describes long-term follow-up, complications and patency rates of the mid-thigh ‘adductor loop’ arteriovenous graft. Methods: 50 mid-thigh loop arteriovenous grafts have been inserted into 48 patients in our unit over the past 11 years. A prospective database was collected on patients receiving an arteriovenous graft at our unit by the senior author. All remained under the care of our unit ensuring accurate follow-up data collection and database was updated at regular intervals. Results: Death-only censored primary patency at 1, 3 and 5 years was 76%, 44% and 23%, respectively. Patients receiving transplants were not censored as follow-up of the arteriovenous grafts was possible. Secondary patency at 1, 3 and 5 years was 95%, 63% and 45%. These rates are higher than previous studies looking at lower limb arteriovenous grafts. Graft thrombosis occurred in 14 patients (28%). Six patients were treated for an infection (12%) but only four grafts were excised; much lower than documented in previous studies. Conclusion: Autogenous venous access remains the perceived gold standard for patients requiring dialysis for end stage renal failure, despite some published data reporting poor outcomes. We have shown that adductor loop arteriovenous grafts can be a reliable, safe and long-term alternative in those whom fistula formation is not possible and may have a role earlier in the patient journey than previously thought, as a result of good patency and lower complications.
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Affiliation(s)
- Samantha J McEwan
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Hannah Maple
- Wessex Kidney Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Paul J Gibbs
- Wessex Kidney Centre, Queen Alexandra Hospital, Portsmouth, UK
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Kim D, Bhola C, Eisenberg N, Montbriand J, Oreopoulos G, Lok CE, Roche-Nagle G. Long-term results of thigh arteriovenous dialysis grafts. J Vasc Access 2018; 20:153-160. [PMID: 30045660 DOI: 10.1177/1129729818787994] [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] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION: A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients. METHODS: We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented. RESULTS: In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13-79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients' lifetime on dialysis. CONCLUSION: Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.
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Affiliation(s)
- Denise Kim
- 1 Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Cynthia Bhola
- 2 Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- 1 Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Janice Montbriand
- 3 Department of Anesthesia and Pain Management, Pain Research Unit, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - George Oreopoulos
- 1 Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,4 Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Charmaine E Lok
- 2 Department of Medicine, Division of Nephrology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- 1 Department of Surgery, Division of Vascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,4 Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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9
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Lazarides MK, Argyriou C, Koutsoumpelis A, Georgakarakos EI, Georgiadis GS. Thigh arteriovenous grafts. Quantitative comparison with alternative options: A meta-analysis. J Vasc Access 2018; 19:430-435. [PMID: 29552941 DOI: 10.1177/1129729818762991] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thigh arteriovenous grafts are required in a number of patients with exhausted upper extremity veins and comprise 1%-5% of the total access procedures performed. Alternative autogenous lower extremity options are the rarely used sapheno-tibial arteriovenous fistulae, the saphenous vein transpositions, and the femoral vein transpositions. The latter have proven to be the most durable lower limb access procedures, with low infection rates and their primary patency rates ranged from 74% up to 87% at 2 years. Synthetic thigh grafts are suitable for patients who are not good candidates for any upper limb or any autogenous lower limb access and their secondary patency rates ranged from 54% up to 83% at 2 years. Thigh grafts often get infected and their average weighed infection rate in 920 such grafts included in eight large series was 22.9%. A literature search was performed to evaluate thigh grafts compared with alternative options using meta-analysis. Lower limb accesses were found superior compared to HeRO® device regarding 1-year primary failure rate (odds ratio = 0.28, confidence interval = 0.09-0.88, p = 0.03) and additionally autogenous lower limb accesses were found superior compared to thigh grafts regarding the 1-year primary failure rate (odds ratio = 6.54, confidence interval = 2.29-18.72, p = 0.0005).
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Affiliation(s)
- Miltos K Lazarides
- 1 Medical School, University of Cyprus, Nicosia, Cyprus.,2 Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christos Argyriou
- 2 Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
| | - Andreas Koutsoumpelis
- 2 Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - George S Georgiadis
- 2 Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
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Dumaine C, Espino-Hernandez G, Romann A, Luscombe R, Kiaii M. Femoral Arteriovenous Grafts for Hemodialysis: Retrospective Comparison With Upper Extremity Grafts and Fistulas. Can J Kidney Health Dis 2017; 4:2054358117719747. [PMID: 35186301 PMCID: PMC8851105 DOI: 10.1177/2054358117719747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/15/2017] [Indexed: 11/24/2022] Open
Abstract
Background: Femoral arteriovenous grafts are rarely used to provide vascular access for dialysis patients. This is likely due, in part, to historically high rates of graft loss from infection and thrombosis. However, for selected patients who have exhausted all access options in the upper extremity, femoral grafts can provide additional sites for access creation and may be preferred over central venous catheters. Objective: We sought to demonstrate that femoral grafts can provide a reliable and safe alternative to central venous catheters for selected patients. Methods: A single-center retrospective review in Vancouver, Canada, from April 1, 2008, to March 31, 2012, was conducted. All patients with new arteriovenous access (grafts and fistulas) created during the study period were included in the study population and followed for a minimum of 2 years. Comparisons of patency (primary, secondary, and functional) and complications (infectious and noninfectious) were made between the different access types. Results: Thirteen patients with femoral grafts were compared with 22 patients with arm grafts and 384 patients with fistulas. Femoral grafts had higher rates of thrombosis (46% with a thrombotic event) and a higher requirement for interventions (1.3 angioplasties and 0.12 thrombolytic procedures per patient per year). However, compared with arm grafts, femoral grafts had superior secondary and functional patency. No difference in patency was seen when comparing femoral grafts with upper extremity fistulas. Only 2 patients with femoral grafts required antibiotics for infection, and no grafts were lost to infection. Conclusions: For patients with limited access options remaining, femoral grafts may provide an additional form of vascular access before resorting to catheter use. Our study shows that with appropriate patient selection, femoral grafts have low infection rates and patency that is comparable with other access types.
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Affiliation(s)
- Chance Dumaine
- Division of Nephrology, Department of Medicine, St. Paul’s Hospital, University of Saskatchewan, Saskatoon, Canada
- Chance Dumaine, Division of Nephrology, Department of Medicine, St. Paul’s Hospital, University of Saskatchewan, 434-230 Avenue R South, Saskatoon, Saskatchewan, Canada S7M 2Z1.
| | | | | | - Rick Luscombe
- Providence Health Care, Department of Nursing, Vancouver, British Columbia, Canada
| | - Mercedeh Kiaii
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
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MacRae JM, Dipchand C, Oliver M, Moist L, Yilmaz S, Lok C, Leung K, Clark E, Hiremath S, Kappel J, Kiaii M, Luscombe R, Miller LM. Arteriovenous Access: Infection, Neuropathy, and Other Complications. Can J Kidney Health Dis 2016; 3:2054358116669127. [PMID: 28270919 PMCID: PMC5332082 DOI: 10.1177/2054358116669127] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/04/2016] [Indexed: 12/16/2022] Open
Abstract
Complications of vascular access lead to morbidity and may reduce quality of life. In this module, we review both infectious and noninfectious arteriovenous access complications including neuropathy, aneurysm, and high-output access. For the challenging patients who have developed many complications and are now nearing their last vascular access, we highlight some potentially novel approaches.
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Affiliation(s)
- Jennifer M MacRae
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Matthew Oliver
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Louise Moist
- Department of Medicine, University of Western Ontario, London, Canada
| | - Serdar Yilmaz
- Department of Surgery, University of Calgary, Alberta, Canada
| | - Charmaine Lok
- Faculty of Medicine, University Health Network, University of Toronto, Ontario, Canada
| | - Kelvin Leung
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Edward Clark
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | | | - Joanne Kappel
- Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mercedeh Kiaii
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rick Luscombe
- Department of Nursing, Providence Health Care, Vancouver, British Columbia, Canada
| | - Lisa M Miller
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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12
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Parekh VB, Niyyar VD, Vachharajani TJ. Lower Extremity Permanent Dialysis Vascular Access. Clin J Am Soc Nephrol 2016; 11:1693-1702. [PMID: 27235473 PMCID: PMC5012475 DOI: 10.2215/cjn.01780216] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hemodialysis remains the most commonly used RRT option around the world. Technological advances, superior access to care, and better quality of care have led to overall improvement in survival of patients on long-term hemodialysis. Maintaining a functioning upper extremity vascular access for a prolonged duration continues to remain a challenge for dialysis providers. Frequently encountered difficulties in clinical practice include (1) a high incidence of central venous catheter-related central vein stenosis and (2) limited options for creating a functioning upper extremity permanent arteriovenous access. Lack of surgical skills, fear of complications, and limited involvement of the treating nephrologists in the decision-making process are some of the reasons why lower extremity permanent dialysis access remains an infrequently used option. Similar to upper extremity vascular access options, lower extremity arteriovenous fistula remains a preferred access over arteriovenous synthetic graft. The use of femoral tunneled catheter as a long-term access should be avoided as far as possible, especially with the availability of newer graft-catheter hybrid devices. Our review provides a summary of clinical evidence published in surgical, radiology, and nephrology literature highlighting the pros and cons of different types of lower extremity permanent dialysis access.
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Affiliation(s)
| | | | - Tushar J. Vachharajani
- Division of Nephrology, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
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Little MD, Allon M, McNamara MM, Ong S, Lockhart ME, Young CJ, Robbin ML. Risk Evaluation of Immediate Surgical Failure During Thigh Hemodialysis Graft Placement by Sonographic Screening. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1613-1619. [PMID: 26269300 DOI: 10.7863/ultra.15.14.10002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 12/07/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether preoperative sonographic evaluation of vascular diameters and calcification identifies patients at risk for immediate technical failure of thigh hemodialysis grafts. METHODS A retrospective analysis of 143 chronic hemodialysis patients who underwent thigh graft placement was performed. All patients underwent preoperative sonography to assess arterial and venous waveforms and vascular diameters. The degree of arterial calcification was assessed retrospectively. Patient characteristics and graft outcomes were examined. Statistical analyses were performed, with P< .05 considered clinically significant. RESULTS Sonography identified no or mild arterial calcification in 113 of 143 patients (79%) and moderate to severe calcification in 30 of 143 patients (21%). Primary surgical technical failure occurred in 23% of patients (7 of 30) with moderate to severe calcification, compared to 3.5% (4 of 113) of those with no or mild calcification (hazard ratio, 6.59; 95% confidence interval, 2.06-21.05; P = .002). Cumulative graft survival (time to permanent failure) was shorter in patients with moderate to severe arterial calcification (3-year graft survival, 37% versus 56%; hazard ratio, 2.32; 95% confidence interval, 1.48-6.69; P= .003) but was not significantly associated with venous (P= .82) or arterial (P = .43) diameters. CONCLUSIONS Preoperative sonographic assessment of thigh vessel diameters and calcification can identify patients who may be at risk for immediate technical graft failure and decreased cumulative graft survival. The use of sonography as a screening examination may improve preoperative assessment and surgical planning of hemodialysis thigh grafts.
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Affiliation(s)
- Mark D Little
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA.
| | - Michael Allon
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Michelle M McNamara
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Song Ong
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Mark E Lockhart
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Carlton J Young
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA
| | - Michelle L Robbin
- Department of Radiology (M.D.L., M.M.M., M.E.L., M.L.R.) and Divisions of Nephrology (M.A., S.O.) and Transplant Surgery (C.J.Y.), University of Alabama at Birmingham, Birmingham, Alabama USA
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Abdominal Wall Grafts: A Viable Addition to Arteriovenous Access Strategies. Ann Vasc Surg 2015; 30:105-9. [PMID: 26166540 DOI: 10.1016/j.avsg.2015.04.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 04/13/2015] [Accepted: 04/17/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND We seek to present our experience with innovative abdominal wall arteriovenous access grafts for patients who have run out of traditional dialysis access options. METHODS We retrospectively reviewed our cohort of patients who have undergone creation of abdominal wall grafts. In all patients, an iliac artery was used for inflow and either an iliac vein or the distal inferior vena cava (IVC) was use for the outflow. Ringed polytetrafluorethylene (PTFE), nonringed PTFE, and bovine carotid artery were used as access conduits. RESULTS Our 12-patient cohort had a mean primary patency of 17.4 months with mean secondary patency of 33 months. There were no operative deaths noted and 4 total graft infections. CONCLUSIONS Abdominal wall grafts with iliac vessel inflow and/or outflow represent viable alternatives for patients who have exhausted more traditional dialysis access options.
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Abstract
Lower limb vascular access is used as an access site in patients in whom all upper limb possibilities for arteriovenous access creation are exhausted or with bilateral upper limb central vein occlusions. Autologous arteriovenous fistulae (AVF) using the greater saphenous vein have disappointing results apart from the isolated success. Autologous AVF using the femoral vein transposition have good results both in terms of long-term patency and are associated with a 10-fold reduction in infection risk compared with arteriovenous grafts (AVGs). However, a femoral vein transposition is a major undertaking and is associated with an increased risk of ischaemic complications. It is not a good option for patients with established peripheral arterial disease, but may be a good alternative for the younger patient with a high infection risk. The type of lower-extremity vascular access should be carefully tailored to the individual patient.
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Ponikvar R. Arteriovenous grafts in the thigh: an excellent hemodialysis vascular access when arm vasculature is exhausted. Ther Apher Dial 2014; 17:416-8. [PMID: 23931882 DOI: 10.1111/1744-9987.12089] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of our retrospective analysis with prospective collected data was to evaluate the patency of thigh expanded polytetrafluoroethylene (ePTFE) arteriovenous (AV) grafts, which were placed in chronic hemodialysis patients by the same interventional nephrologist skilled in hemodialysis access vascular surgery. From February 1991 until March 2013, 35 thigh ePTFE grafts were placed in 31 chronic hemodialysis patients. Twenty (57%) were women, mean age 58.7 ± 14.5, dialysis vintage 11.9 ± 7.3 years, mean number of previous vascular accesses 4.4 ± 1.9. Two of the 35 (5.7%) grafts were lost to follow-up, immediate failure occurred in 1/35 (2.8%) grafts, and thrombosis appeared within 30 days in 2/35 (5.7%) grafts. Four of the 31 patients died with functioning grafts, while in 9/31 patients the grafts are still patent. In the remaining 17 AV grafts that thrombosed, no surgical intervention was performed in 8/17, while 18 thrombectomies (two per graft) were performed in 9/17 to maintain graft patency. The immediate success rate was 97.1%. Primary patency was from 0-3251 days, on average 906 ± 898, median 472, cumulative patency (N = 33) was from 0-3251 days, on average 1174 ± 954, median 966. Cumulative patency of the grafts that were patent for more than 30 days (N = 30) was from 153-3251 days, on average 1298 ± 921, median 1207. The ePTFE graft survival after the 1st year was 78%, after the 2nd year 74%, after the 3rd year 66%, after the 4th year 56%, after the 5th year 52%, and after the 9th year 13 %. The longest patency was 3251 days without any intervention. Steal syndrome occurred in two patients after 2522 and 275 days after fistula placement.
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Affiliation(s)
- Rafael Ponikvar
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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Ong S, Barker-Finkel J, Allon M. Long-term outcomes of arteriovenous thigh grafts in hemodialysis patients: a comparison with tunneled dialysis catheters. Clin J Am Soc Nephrol 2013; 8:804-9. [PMID: 23371958 DOI: 10.2215/cjn.09240912] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Arteriovenous thigh grafts are a potential vascular access option in hemodialysis patients who have exhausted all upper-limb sites. This study compared the outcomes of thigh grafts with outcomes obtained with dialysis catheters. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A prospective vascular access database was queried to identify 209 thigh grafts placed from January 1, 2003, to June 30, 2011. The following were calculated: secondary graft survival (from graft creation to permanent failure), assisted primary graft survival (from graft creation to first thrombosis), and infection-free graft survival (from graft creation to first graft infection). Graft outcomes were compared with those observed with 472 tunneled internal jugular dialysis catheters. RESULTS The median duration of patient follow-up was 340 days for grafts and 91 days for catheters. The surgical technical failure rate of thigh grafts was 8.1% and was higher in patients with vascular disease (hazard ratio [HR], 2.94; 95% confidence interval [CI], 1.07-8.04; P=0.03). Secondary and assisted primary graft survival rates at 1, 2, and 5 years were 62%, 54%, and 38% and 38%, 27%, and 17%, respectively. Infection-free graft survival rates at 1, 2, and 5 years were 79%, 73%, and 61%. Secondary survival was much worse for dialysis catheters than thigh grafts (HR, 4.44; 95% CI, 3.65-5.22; P<0.001). Likewise, infection-free survival was far worse for catheters than for thigh grafts (HR, 3.77; 95% CI, 2.80-4.82; P<0.001). CONCLUSIONS Thigh grafts are a viable vascular option in patients who have exhausted upper-extremity options. Outcomes with thigh grafts are superior to those obtained with dialysis catheters.
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Affiliation(s)
- Song Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA
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Ramani K, Kallam A, Zibari G, Caldito G, Ram SJ, Abreo KD, Sequeira A. Graftula: a composite access consisting of a graft used to repair a dysfunctional hemodialysis fistula. Semin Dial 2012; 26:355-60. [PMID: 23004012 DOI: 10.1111/sdi.12004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Nonmaturing or dysfunctional hemodialysis fistulas are often repaired with interposition grafts placed either within the fistula (fistula-to-fistula configuration), or connected to another vein (fistula-to-vein configuration). The goal of this study was to compare the survival and usefulness of the composite accesses thus created, which we call "graftulas," with upperarm grafts. This was a retrospective study wherein we determined the survival and thrombosis rates of graftulas (n=24) and upper arm grafts (n=31) placed 1/1/07 through 12/31/09 and followed through 11/30/10. Graftulas resembled grafts as most (96%) were successfully cannulated in 65 ± 43 days. Survival of graftulas was also similar to grafts (58%, 47%, and 32% vs. 56%, 47%, and 39% at 1, 2, and 3 years respectively, p=0.60). However, graftulas had a lower thrombosis rate than grafts (0.5 vs. 1.2 per patient year, p=0.04), and in the fistula-to-fistula configuration, a 2-year thrombosis-free survival of 78%. Total survival of the access site (fistula+graftula) was 92%, 73%, and 42% at 1, 3, and 5 years, respectively. Graftulas possess certain beneficial properties of fistulas and grafts that allows for continued use of the original access site.
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Affiliation(s)
- Karthik Ramani
- Division of Nephrology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Dageforde LA, Bream PR, Moore DE. Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model. J Surg Res 2012; 177:165-71. [DOI: 10.1016/j.jss.2012.04.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 04/09/2012] [Accepted: 04/18/2012] [Indexed: 11/17/2022]
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Carsten CG. Lower extremity arteriovenous hemodialysis access: an important adjunct in select patients. Semin Vasc Surg 2011; 24:102-7. [PMID: 21889098 DOI: 10.1053/j.semvascsurg.2011.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Given the current survival rates of patients receiving hemodialysis, it has become increasingly common for patients to exhaust their upper extremity access options. Likewise, overzealous catheter use can lead to central venous occlusion or stenosis, further limiting the upper extremity access options. In these patients, use of the lower extremities for access is often required. Fortunately, there are a number of options available that have acceptable durability and utility. The purpose of this article is to review the various techniques available for placement of hemodialysis access in the lower extremity and discuss their results.
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Affiliation(s)
- Christopher G Carsten
- Department of Surgery, University of South Carolina School of Medicine, Greenville Hospital System, Greenville, SC 29605, USA.
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Harish A, Allon M. Arteriovenous Graft Infection: A Comparison of Thigh and Upper Extremity Grafts. Clin J Am Soc Nephrol 2011; 6:1739-43. [DOI: 10.2215/cjn.00490111] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ponikvar R, Premru V, Kersnič B. Surgical Thrombectomy of Thrombosed Arteriovenous Grafts by Interventional Nephrologists. Ther Apher Dial 2011; 15:306-10. [DOI: 10.1111/j.1744-9987.2011.00956.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shingarev R, Maya ID, Barker-Finkel J, Allon M. Arteriovenous graft placement in predialysis patients: a potential catheter-sparing strategy. Am J Kidney Dis 2011; 58:243-7. [PMID: 21458898 DOI: 10.1053/j.ajkd.2011.01.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 01/20/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND When predialysis patients are deemed unsuitable candidates for an arteriovenous fistula, current guidelines recommend waiting until just before or after initiation of dialysis therapy before placing a graft. This strategy may increase catheter use when these patients start dialysis therapy. We compared the outcomes of patients whose grafts were placed before and after dialysis therapy initiation. STUDY DESIGN Retrospective analysis of a prospective computerized vascular access database. SETTING & PARTICIPANTS Patients with chronic kidney disease receiving their first arteriovenous graft (n = 248) at a large medical center. PREDICTOR Timing of graft placement (before or after initiation of dialysis therapy). OUTCOME & MEASUREMENTS Primary graft failure, cumulative graft survival, catheter dependence, and catheter-related bacteremia. RESULTS The first graft was placed predialysis in 62 patients and postdialysis in 186 patients. Primary graft failure was similar for pre- and postdialysis grafts (20% vs 24%; P = 0.5). Median cumulative graft survival was similar for pre- and postdialysis grafts (365 vs 414 days; HR, 1.22; 95% CI, 0.81-1.98; P = 0.3). Median duration of catheter dependence after graft placement in the postdialysis group was 48 days and was associated with 0.63 (95% CI, 0.48-0.79) episodes of catheter-related bacteremia per patient. LIMITATIONS Retrospective analysis, single medical center. CONCLUSION Grafts placed predialysis have primary failure rates and cumulative survival similar to those placed after starting dialysis therapy. However, postdialysis graft placement is associated with prolonged catheter dependence and frequent bacteremia. Predialysis graft placement may decrease catheter dependence and bacteremia in selected patients.
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Affiliation(s)
- Roman Shingarev
- Division of Nephrology, University of Alabama at Birmingham, USA
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Sherman RA. Briefly Noted. Semin Dial 2010. [DOI: 10.1111/j.1525-139x.2010.00810.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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