Selective non-operative management of pseudoaneurysms and arteriovenous fistulae complicating femoral artery catheterization.

Femoral arterial pseudoaneurysms or arteriovenous fistulae may sometimes complicate percutaneous femoral artery catheterization procedures. Most surgeons recommend prompt operative repair because of the unfavorable natural history of pseudoaneurysms or arteriovenous fistulae secondary to violent or accidental arterial trauma. However, the natural history of catheterization-induced pseudoaneurysms and arteriovenous fistulae has not been well documented. Accordingly, we prospectively studied the natural history of 22 pseudoaneurysms, 8 arteriovenous fistulae, and 3 combined lesions, identified by duplex scan in 32 patients following trans-femoral cardiac, peripheral vascular, or vascular access arterial catheterization procedures. Angiographic procedures were performed with the use of 5-8F introducer sheaths. A femoral artery complication was significantly more likely to result from coronary balloon angioplasty (9/304; 3.0%) than from diagnostic cardiac catheterization (21/2476; 0.8%) (p less than 0.003; chi square). Fourteen patients (13 pseudoaneurysms, 1 combined pseudoaneurysm/fistulae) underwent surgical repair. Pain and/or enlarging hematoma resulted in repair within two days of the diagnosis in 8 patients. The need for chronic anticoagulation prompted elective repair in 2 patients. A pseudoaneurysm was repaired in one patient five days following catheterization when it became painful. In three stable patients, asymptomatic pseudoaneurysms were repaired electively during another surgical procedure. There were no operative deaths. One patients (7%) developed a wound infection postoperatively. Eighteen patients (19 arterial lesions: 9 pseudoaneurysms, 8 arteriovenous fistulae, 2 combined pseudoaneurysms/arteriovenous fistulae) with improving symptoms and stable physical signs were followed by serial clinical evaluation and duplex scans. Seventeen of 19 (89%) of these lesions resolved spontaneously within 5-90 days (mean 30.7 days).(ABSTRACT TRUNCATED AT 250 WORDS)     

Iatrogenic arteriovenous fistula during lumbar microdiscectomy

Vascular lacerations, arteriovenous fistulae, and pseudoaneurysms are rare, but potentially life threatening, complications of lumbar disk surgery. These iatrogenic vascular injuries may present with significant hypotension during the perioperative period. Early diagnosis and surgical repair may decrease morbidity and mortality. We discuss perioperative implications of postdiscectomy vascular injuries in this report.     

Successful interventional treatment of renal insufficiency caused by renal artery pseudoaneurysm with concomitant arteriovenous fistula

Asymptomatic arteriovenous fistulae and pseudoaneurysms are common after renal biopsy. We present a patient with a single kidney and symptomatic pseudoaneurysm of the renal artery with concomitant arteriovenous fistula as a rare complication following surgical embolectomy. The patient developed renal insufficiency because of a significant degree of vascular steal caused by the fistula. Dialysis was performed for more than 6 months until the fistula was diagnosed. The fistula and the pseudoaneurysm were successfully treated by superselective arterial embolization with metallic coils. Renal function improved within the next 2 weeks and no further dialysis was necessary.     

Surgical treatment of post—traumatic pseudoaneurysms and arteriovenous fistulas

Objective:To report the experience in the diagnosis and treatment of post-traumatic pseudoaneurysms and arteriovenous fistulas.Methods:A series of 30 patients(11 women and 19 men) with posttraumatic pseudoaneurysms were reviewed retrospectively.Among them 7 patients (5 women and 2 men) were associated with arteriovenous fistula.Results:The causes included sharp penetration trauma(18 cases),blunt trauma (6 cases) and iatrogenic arterial injury (6 cases).The main clinical manifestations consisted of local pulsatile mass (26 cases),vascular bruits (19 cases),thrill (13 cases),ischemia of distal limb (9 cases),neuropathy (5 cases) and pseudoaneurysm rupture (2 cases).All patients underwent surgery.The operations included:ligation of the vessels (12 cases),surgical resection and primary suture repain of the vascular defect or anastomosis (11 cases),vascular reconstruction with autogenous saphenous vein (3 cases) and synthetic vascular graft (4 cases).Conclusions:Because of the imminent clinical course,early operation is usually indicated.The operative treatment is effective and safe for most of the patients with post-traumatic pseudoaneurysms and arteriovenous fistulas.     

Hemodialysis access placement with preoperative noninvasive vascular mapping: comparison between patients with and without diabetes

We retrospectively analyzed data on preoperative vascular mapping in 195 consecutive patients to investigate the common belief that patients with diabetes are poor candidates to have an arteriovenous fistula placed as dialysis access because they lack suitable blood vessels. There was no difference in venous diameter, arterial diameter, and arterial peak systolic velocity measurements between patients with and without diabetes. Patients with diabetes had a greater prevalence of vascular calcifications and greater cuff measurements of systolic segmental arterial pressure. In 140 of 195 patients, subsequent vascular access surgery had been performed in our institution, and 127 of these patients were on hemodialysis therapy at the end of the study period. There was no difference in the prevalence of fistula placement (66% versus 60%; chi-square = 2.6; df = 2; P = 0.28, not significant [NS]) and percentage of functioning fistulae between patients with and without diabetes (67% versus 62%; chi-square = 0.27; df = 1; P = 0.61, NS). The percentage of patients dialyzed through a temporary catheter was equal in patients with and without diabetes (18%). In summary, patients with diabetes seem to be as good candidates for arteriovenous fistula placement as patients without diabetes. Additional studies are required to determine the long-term outcome of fistulae in patients with diabetes.     

Single limb patency of polytetrafluoroethylene dialysis loop grafts maintained by traumatic fistulization

The purpose of this report is to describe an unusual presentation of obstructive neointimal hyperplastic lesions in loop prosthetic dialysis grafts. The case histories and imaging studies of two patients with partial graft thrombosis are presented. The literature of unexpected fistulae from prosthetic dialysis grafts to adjacent veins is reviewed. Signs and symptoms that would lead a clinician to suspect the diagnosis are emphasized. There were two dialysis grafts with partial thrombosis and arterial limb patency maintained by iatrogenic fistula. These fistulae occurred from the erosion of pseudoaneurysms in one case and an apparent needle stick without pseudoaneurysm in the other. Both grafts had high-grade stenotic lesions affecting the venous outflow. In the first case this was not recognized until the graft reclotted 2 days after thrombectomy. In the most extreme cases of graft/vein fistulae, i.e., partial graft thrombosis with arterial limb patency maintained by the fistula there is always associated venous anastomotic or outflow stenoses which must be addressed. Correspondence to: A. Hooson, Oregon Surgical Consultants, P.C., 1130 NW 22nd Avenue #300, Portland, OR 97210, USA.     

Intraoperative microdoppler monitoring for spinal dural arteriovenous fistulae

BACKGROUND: One of the most important goals in the surgical treatment of spinal dural arteriovenous fistulae is complete interruption of the flow in the fistula. To confirm complete interruption, we use intraoperative microdoppler monitoring. METHODS: Three patients with spinal dural arteriovenous fistulae with perimedullary venous drainage underwent surgical treatment using microdoppler monitoring. All of them suffered from congestive myelopathy before treatment. Microdoppler monitoring was performed on the perimedullary draining vein to detect the arterial spectrum before and after the interruption of the arteriovenous shunt. RESULTS: In all patients, an arterial spectrum was detected on the dorsal perimedullary vein. Sequential monitoring demonstrated the effects of each surgical procedure, which included epidural coagulation of the fistulae or intradural ligation of the retrogradely draining radiculomedullary veins. After complete interruption of the fistula, the arterial spectrum disappeared completely. In a patient with duplicated dural arteriovenous fistulae, the direction of the flow of the second arteriovenous shunt could be demonstrated by microdoppler monitoring combined with temporary clipping. This is especially useful in a complex case with duplicated fistulae. In all patients, postoperative angiography demonstrated complete disappearance of the arteriovenous fistulae. The patients all showed remarkable improvement with no therapeutic morbidity. CONCLUSION: Intraoperative microdoppler monitoring is an easily available and useful technique to safely confirm complete obliteration of spinal dural arteriovenous fistulae.     

Covered stent exclusion of dialysis access pseudoaneurysms

BACKGROUND: The traditional repair of hemodialysis graft pseudoaneurysms has been to surgically replace that segment of involved PTFE graft material or autogenous vein. We report a novel approach to these lesions, employing a covered stent (Wallgraft) for exclusion of arteriovenous graft (AVG) and arteriovenous fistula (AVF) pseudoaneurysms. METHODS: Ten patients with AVG or AVF pseudoaneurysms were treated endoluminally by covered stent exclusion. Wallgraft implantations were performed in the operating room with interventional capabilities under local anesthesia through a percutaneous access. Follow-up included physical examination at 2 weeks and duplex ultrasound of AVG/ AVF at 6 months after surgery. RESULTS: Ten patients with pseudoaneurysmal degeneration of their AVG/AVF were identified. The mean diameter of the pseudoaneurysmal segment was 3 cm (range, 1.5-5 cm). Immediately following covered stent implantation all the patients had palpable pulses in the pseudoaneurysms despite adequate coverage by angiography. At the 2-week follow-up visit all had lost the palpable pseudoaneurysm pulsation while the AVGs remained functional in nine patients. One patient had early thrombosis of the AVG. The follow-up duplex scans at 6 months showed complete exclusion of the pseudoaneurysms in seven patients. Two patients had thrombosis of their dialysis access, at 3 weeks (n = 1) and 3 months (n = 1) post-implantation. CONCLUSION: Endovascular covered stent exclusion of AV dialysis access pseudoaneurysms is safe and technically feasible in eliminating flow through dialysis access pseudoaneurysms and represents a novel and simple approach to this common problem, prolonging the functional life of the access site.     

Aktuelle Studienlage zur Shuntchirurgie

A well-functioning vascular access is a prerequisite for life-sustaining dialysis treatment in patients with chronic renal failure. Complications of a vascular access belong to the major causes of the high morbidity and mortality in dialysis-dependent patients. The outcome of the dialysis access and patient’s quality of life is dependent on the timing of access creation, selection of the appropriate vascular region, type of access and the follow-up. Autologous arteriovenous (a.v.) fistulae are considered to be the first choice dialysis access. Compared to an alloplastic access (prosthetic grafts, dialysis catheters) a.v. fistulae offer the highest patency and lowest complication rates. Autologous arteriovenous grafts remain the second choice for dialysis access mainly due to high occlusion rates. Particularly pharmacological and new technical approaches have recently provided further progress in prevention of anastomotic stenoses caused by neo-intimal hyperplasia. Access complications are increasingly being managed by interventional therapy. New thrombectomy devices have improved results of interventional revascularization of occluded a.v. accesses but up to now have not replaced surgical techniques. Stenotic lesions of dialysis accesses are predominantly treated by interventional methods. Apart from the sole use of balloon angioplasty, different recommendations for additional interventions have emerged depending on shunt localization and type of stenosis. Shunt-induced steal syndromes require differentiated therapy which considers factors such as access flow and localization as well as vascular status and patient co-morbidities.     

Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms

PURPOSE: We previously reported preliminary data on a new procedure that we developed for the treatment of femoral pseudoaneurysms after catheterization. This study presents our current results of percutaneous ultrasound-guided thrombin injection for treating pseudoaneurysms that arise from various locations and causes. METHODS: Between February 1996 and May 1999, we performed thrombin injection of 83 pseudoaneurysms in 82 patients. There were 74 femoral pseudoaneurysms: 60 from cardiac catheterization (36 interventional), seven from peripheral arteriography (four interventional), five from intra-aortic balloon pumps, and two from dialysis catheters. There were nine other pseudoaneurysms: five brachial (two cardiac catheterization, two gunshot wounds, one after removal of an infected arteriovenous graft), one subclavian (central venous catheter insertion), one radial (arterial line), and one distal superficial femoral and one posterior tibial (both after blunt trauma). Twenty-nine pseudo-aneurysms were injected while on therapeutic anticoagulation. Patients underwent repeat ultrasound examination within 5 days and after 4 weeks. RESULTS: Eighty-two of 83 pseudoaneurysms had initial successful treatment by this technique, including 28 of 29 in patients who were undergoing anticoagulation therapy. The only complication was thrombosis of a distal brachial artery, which resolved spontaneously. There were early recurrences in seven patients: four patients underwent successful reinjection; reinjection failed in two patients, who underwent surgical repair; and one patient had spontaneous thrombosis on follow-up. After 4 weeks, ultrasound examinations were completely normal or showed some residual hematoma, and there were no recurrent pseudoaneurysms. CONCLUSION: Ultrasound-guided thrombin injection of pseudoaneurysms has excellent results, which support its widespread use as the primary treatment for this common problem.     

火器性四肢动脉伤：附50例报告

作者报告５０例５２条四肢火器性动脉伤，其中枪弹伤３７例，弹片伤１３例；急性动脉伤３２例（３３条），晚期动脉伤８例，假性动脉瘤７例，动静脉瘘３例（４条）。平均随访２４．２个月，无一例死亡，修复血管通畅率９３％，截肢率９．８％，肢体缺血性挛缩发生率１０．９％。作者强调，早期诊断、早期正确处理此类动脉伤是成功的关键。应争取在伤后６～１２小时内修复损伤血管。根据临床表现可作出诊断，急性动脉伤一般不做血管造影，对可疑肢体主要动脉伤应积极手术探查。根据伤情采用对端吻合或自体静脉移植修复血管，不主张用人造血管修复，血管部分断裂不宜做侧壁吻合。晚期动脉伤应争取修复血管以改善肢体循环。假性动脉瘤和动静脉瘘宜早期切除修复血管，待伤口愈合、组织柔软后即可手术。     

A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study

Penetrating proximity extremity trauma (PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152 injuries from PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152 wounds, of which 16 (10.5%) were in major arteries. One acute arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun trauma was the mechanism which carried the greatest risk of significant vascular injury. Although "soft" clinical signs were significantly more predictive of vascular injury following PPET than proximity alone (p less than 0.0005), 50% of all injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of vascular injury; and 4) with the exception of shotgun wounds, AG did not appear to be a cost effective screening modality, since detection of a single vascular injury requiring surgery cost $66,420.00.     

Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents

OBJECT: The authors describe their preliminary clinical experience with the use of endovascular stents in the treatment of traumatic vascular lesions of the skull base region. Because adequate distal exposure and direct surgical repair of these lesions are not often possible, conventional treatment has been deliberate arterial occlusion. The purpose of this report is to demonstrate the safety and efficacy as well as limitations of endovascular stent placement in the management of craniocervical arterial injuries. METHODS: Six patients with vascular injuries were treated using endovascular stents. There were two arteriovenous fistulas and two pseudoaneurysms of the distal extracranial internal carotid or vertebral arteries resulting from penetrating trauma, and two petrous carotid pseudoaneurysms associated with basal skull fractures. In one patient a porous stent placement procedure was undertaken as well as coil occlusion of an aneurysm, whereas in the remaining five patients covered stent grafts were used as definitive treatment. There were no procedural complications. One patient in whom there was extensive traumatic arterial dissection was found to have asymptomatic stent thrombosis when angiography was repeated 1 week postoperatively. This was the only patient whose associated injuries precluded routine antithrombotic or antiplatelet therapy. Follow-up examinations in the remaining five patients included standard angiography (four patients) or computerized tomography angiography (one patient), which were performed 3 to 6 months postoperatively, and clinical assessments ranging from 3 months to 1 year in duration (mean 9 months). In all five cases the vascular injury was successfully treated and the parent artery remained widely patent. No patient experienced aneurysm recurrence or hemorrhage, and there were no thromboembolic complications. CONCLUSIONS: The authors' experience demonstrates that endovascular treatment of traumatic vascular lesions of the skull base region is both feasible and safe. The advantages of minimally invasive stent placement and parent artery preservation make this procedure for repair of neurovascular injuries a potentially important addition to existing methods.     

A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty

Over a 14-month period patients undergoing 144 percutaneous transluminal coronary angioplasty procedures were evaluated for the presence of complications at the femoral puncture site. After percutaneous transluminal coronary angioplasty each patient was examined by a surgeon, and then a color-flow duplex scan of the groin was obtained. On the initial scan eight pseudoaneurysms, three arteriovenous fistulas, one combined arteriovenous fistula-pseudoaneurysm, and one thrombosed superficial femoral artery were detected for a major vascular complication rate of 9%. Pseudoaneurysm formation was associated with the use of heparin after removal of the arterial sheath. Seven pseudoaneurysms (initial extravascular cavity size range 1.3 to 3.5 cm) were followed with weekly duplex scans, and all thrombosed spontaneously within 4 weeks of detection. The three patients with isolated arteriovenous fistulas were each followed for at least 8 weeks, and the arteriovenous fistulas persisted. Early surgical intervention for postcatheterization femoral pseudoaneurysms is usually unnecessary as thrombosis often occurs spontaneously. We would advocate an operative approach for pseudoaneurysms that are symptomatic, expanding, or associated with large hematomas. Iatrogenic femoral arteriovenous fistulas should be considered for elective repair, but this may be delayed for several weeks without adverse sequelae.     

Patent foramen ovale, dialysis and microembolization

Background: Haemodialysis (HD) circuits are known to produce microemboli. Patent foramen ovale (PFO) may be important in HD patients by allowing right to left intracardiac shunting of microemboli (blood clots or microbubbles), which may pass into the cerebral circulation. Methods: We undertook bubble contrast transthoracic echocardiography to identify PFO in HD patients and in a control population of peritoneal dialysis patients. We interrogated draining arteriovenous fistulae to confirm that microemboli are created during HD. We then undertook transcranial Doppler scanning of the middle cerebral artery before and during dialysis, with and without Valsalva augmentation, to detect cerebral microemboli in HD patients and in the control group. Results: Eighty patients (age 60.4 ± 15.0 years) were recruited to the study. In 12 of 51 HD patients and five of 29 peritoneal dialysis patients a PFO was found (21.3%). Ultrasound scanning of draining arteriovenous fistulae showed a significant difference in the number of microemboli before (1.63 ± 3.47 hits per 5 min) and during (31.6 ± 28.9 hits per 5 min) HD (P = 0.012). However, there was no evidence of microembolization to the middle cerebral artery before or during HD in the study or control groups. Conclusions: Although microemboli are detectable in the draining arteriovenous fistulae of patients undergoing HD, there was no evidence of cerebral microembolization in the middle cerebral artery during HD in those with or without a PFO. The results contrast with previous reports demonstrating microemboli in the carotid circulation during HD.     

Clinical application of endovascular grafts in aortoiliac occlusive disease and vascular trauma

Intravascular stents and stented grafts are becoming important tools for the management of a variety of vascular lesions. This review addresses the technical feasibility and early results of aortoiliac endovascular reconstructions for limb salvage as well as the placement of stented grafts for the treatment of traumatic arterial lesions. Eighteen patients with limb-threatening ischemia secondary to aortoiliac and femoropopliteal occlusive disease who were poor candidates for standard arterial bypass operations and eight patients with traumatic arterial lesions (two arteriovenous fistulas; six pseudoaneurysms) were treated with endovascular stented grafts. These were constructed of 6-mm tubular polytetrafluoroethylene (GORE-TEX) and balloon-expandable stents (Palmaz). Technical success was achieved in 95% of grafts placed to treat long segment occlusive disease of the iliofemoral arteries and in 100% of grafts placed to treat traumatic arterial injuries. There were no deaths and only minor complications in both groups. Although the early results with these grafts are encouraging, long-term follow-up is needed before such devices can be recommended for widespread use.     

Percutaneous angioplasty of arteriovenous (Brescia-Cimino) fistulae in children

 The development of a stenosis in a Brescia-Cimino fistula is a major clinical problem that threatens vascular access for dialysis. We reviewed the case notes of 46 children undergoing hemodialysis via Brescia-Cimino fistulae. Ten children (mean age 12.5 years) developed 14 stenoses located in the venous (10), anastomotic (3), or arterial (1) part of the fistula. Three (1 arterial and 2 anastomotic stenoses) of the 14 stenoses were treated surgically; the remaining 11 (10 venous and 1 anastomotic stenoses) were treated by angioplasty. Seventeen angioplasty procedures were performed by the percutaneous venous route under local anesthesia. Mean follow-up was 24 months. Restenosis within 6 months occurred in 5 patients, predominantly those who had angioplasty with low balloon inflation pressures; 1 was treated surgically; 4 underwent repeat angioplasty using higher balloon inflation pressures (3 patients) or a bigger balloon (1 patient). None subsequently developed restenosis. Angioplasty can be safely used to treat stenosis of arteriovenous fistulae, with a high initial (60% freedom from restenosis at 6 months) success rate. In summary, balloon angioplasty, repeated if necessary, is a safe and effective treatment for the majority of stenoses occurring in Brescia-Cimino fistulae. Restenosis can be safely treated by further angioplasty, which is associated with a high rate of ultimate clinical success. Received July 15, 1996; received in revised form and accepted December 18, 1996     

Surgical bypass of symptomatic central venous obstruction for arteriovenous fistula salvage in hemodialysis patients

Venous hypertension due to proximal central venous outflow obstruction coexisting with a functioning arteriovenous fistula in the ipsilateral arm presents with a complex management problem in hemodialysis patients. Ligation of the arteriovenous communication is the simplest procedure to relieve symptoms; however, this sacrifices the patient's hemodialysis access, which may be the only available access in that patient. Surgical bypass of the occlusion is a potential option as it obviates the symptoms of venous hypertension while preserving dialysis access. Our objective was to evaluate our experience and outcome with dialysis patients undergoing surgical bypass for symptomatic central venous obstruction and dialysis access salvage. There were three hemodialysis patients with severe venous hypertension secondary to subclavian vein obstruction who had functioning ipsilateral arteriovenous fistulae. All underwent cephalic vein (n = 2) or axillary vein (n = 1) to internal jugular vein bypass of the obstructed subclavian segment via an 8-mm polytetrafluoroethylene bridge graft. All patients had unsuccessful percutaneous transluminal angioplasty (PTA) attempts prior to surgical bypass. In two patients, a wire could not be passed through the occlusion; in the third, PTA was only transiently successful despite four repeated procedures. All patients had complete resolution of symptoms without operative mortality. The bypass grafts remained patent, allowing the arteriovenous fistulae to provide functional access for the entire duration of follow-up after surgery (3-8 months). Surgical bypass of a central vein obstruction relieves the symptoms of venous hypertension and prolongs the use of the existing hemodialysis access. This surgical option should be well recognized within the dialysis community.     

True venous aneurysms and arterial "steal" secondary to arteriovenous fistulae for dialysis.

In patients requiring hemodialysis, arteriovenous fistulae may be created using autogenous vessels or prosthetic grafts. Complications of such operations include thrombosis, infection, venous hypertension, pseudoaneurysm, congestive heart failure, true venous aneurysms, and arterial "steal" syndrome. Of these the last two are the least common. On reviewing the English literature (Medline search: 1969-1991) we found only 8 reported cases of true venous aneurysms secondary to creation of an arteriovenous fistulae for dialysis. Hemodynamic assessment has shown that arterial "steal" is frequently present distal to an arteriovenous fistula. However, these patients rarely have ischemic symptoms. Over the last 7 years 236 patients had arteriovenous fistulae created for hemodialysis at our institution. Three of these patients (1.2%) developed true venous aneurysms. One of these 3 patients (0.4%) also had severe hand claudication due to arterial "steal". All of these patients were treated successfully without any complications. The etiology and various therapeutic options for these rare complications are discussed.     

Surveillance policy for early detection of failing arteriovenous fistulae for haemodialysis

We have developed a programme of surveillance for arteriovenousfistulae. Indications for investigation were a reduction ofthrill or pulsation on the fistula, decreasing flow (<200ml/min)and/or increased venous return pressure (> 150 mmHg.) whenon haemodialysis. Between March 1992 and February 1993 we performedintravenous digital subtraction fistulograms in 17 patients.These investigations demonstrated vein stenosis in 11 patients,nine with primary arteriovenous fistulae and in two with secondaryaccess. There was disease of the arterial inflow in one, andno evidence of anatomical problems in the remaining five. Asa result revision surgery was performed in 10 cases and percutaneoustransluminal angioplasty in the remaining two cases. Five patientsunderwent dialysis the following day on the same site, avoidingtemporary access. Sixteen patients (94%) are still using thesame site for haemodialysis at mean follow-up time of 6.1 months(range 2–12 months) and one failed subsequently. Close surveillance of arteriovenous fistulae leads to detectionof stenosis prior to occlusion and intervention increases patency,preserves alternative access sites, and prevents central venouscannulation for temporary access.