Immediate,safe hemodialysis into arteriovenous fistulas created with a new tunneler: An 11 year experience

It seems apparent that application of the tunneler has greatly facilitated the immediate use of graft arteriovenous fistulas. Most new patients admitted with end-stage renal disease have arteriovenous fistulas created, receive hemodialysis appropriately, and are discharged from the hospital within 2 to 4 days. In my experience, there was a significant decrease in the need for externally placed catheters or shunts. These 301 consecutive cases with relatively few early complications attest to the safety of immediate hemodialysis into graft arteriovenous fistulas created with this tunneler.     

Finger necrosis: a rare complication of arteriovenous fistulas created for hemodialysis

Created arteriovenous fistulas for hemodialysis in patients with renal failure can cause problems in the upper extremity. Thrombosis, bleeding, infection, and distal ischemic changes can be seen. Steal is considered as a rare phenomenon. High blood-flow volume through an arteriovenous fistula may cause stealing of blood from forearm arteries which can lead to distal hypoperfusion and peripheral ischemia as well as distal finger-tip amputations and even spontaneous ulcerations. Herein, two patients admitted to our outpatient clinic by finger necrosis have been reported, and the aim of this paper is to highlight a rare but serious complication of arteriovenous fistula and discuss what should be done to prevent finger necrosis and the strategies that can be done in the case of finger necrosis which might be of interest for the clinicians. Level of Evidence: Level V, risk/prognostic study.     

Exotic arteriovenous fistulas for hemodialysis

The rate of patients with exhausted upper extremity arteriovenous fistula (AVF) sites who have lost all chances for a conventional upper extremity AVF has been increasing in line with the general increase in the hemodialysis patient population. In this prospective study, we report the early and late follow-up results of "exotic" AVFs in which central veins are used for the outflow. Patients having no chance for an upper extremity AVF based on previous catheterization, surgical AVF history, detailed physical examination, and radiological assessment, were included in the study. Between June 1999 and January 2003, 27 central AVFs were created with a 6 mm synthetic vascular graft in 26 patients. The inflow artery was the proximal axillary artery in all except one. All but one operation was done by the same surgeon. The outflow vein was the internal jugular vein in 16 and infraclavicular axillary vein in 11 cases. One-year primary and secondary graft patency rates were 33.33 +/- 10.49 and 57.06 +/- 11.29, respectively. The early complications were facial edema and hemiparesis, both of which resolved spontaneously. The only late complication, pseudoaneursym, was treated by a graft interposition. In selected patients who have no suitable upper extremity vessels for an AVF, the central veins may be used with an acceptable success rate. Another advantage of this procedure is the avoidance of undesired femoral interventions; sometimes it may be the only opportunity and lifesaving for the patient.     

Construction of arteriovenous fistulas for hemodialysis.

Establishment of a dependable means of venous access is vitally important to patients who require hemodialysis. Physical examination and phlebography are used to assess the most appropriate site for arteriovenous fistula construction. The radial artery and cephalic vein near the wrist should be used whenever possible, but several alternative procedures are available, including the brachiocephalic fistula, and saphenous vein and bovine heterograft interposition. Each operation contributes immeasurably to the comfort and survival of patients with terminal renal failure, and each must be performed with careful attention to detail.     

尸体动脉建立动静脉内瘘术

目的 动静脉内瘘是慢性肾功能衰竭血液透析患者的重要“生命线”,但一些长期透析患者,由于多次手术及反复穿刺,上肢前臂已无可供做内瘘吻合的动静脉。我们采用尸体动脉作为移植血管制作动静脉内瘘。方法 将尸体动脉用乙醚及无水乙醇处理,保存于75％乙醇内。将尸体动脉作为移植血管制作动静脉内瘘3例。结果 术后血流通畅,血流量200-275ml·min-1。结论 用尸体动脉作为移植血管制作动静脉内瘘效果满意。     

Duplex ultrasound scanning in the assessment of arteriovenous fistulas created for hemodialysis access: comparison with digital subtraction angiography

The results of duplex ultrasound scanning for the diagnosis of stenoses in Brescia-Cimino arteriovenous fistulas and graft arteriovenous fistulas created for hemodialysis access are reported. Quantitative Doppler spectrum analysis of 64 arteriovenous fistulas was correlated with the outcome of digital subtraction angiography. The best Doppler parameter for the detection of a stenosis was the peak systolic frequency. In graft arteriovenous fistulas the use of this parameter resulted in a diagnostic accuracy of 86%, a sensitivity of 92%, and a specificity of 84% in the detection of stenoses. In Brescia-Cimino arteriovenous fistulas the diagnosis of anastomotic stenoses was possible with a diagnostic accuracy of 81%, a sensitivity of 79%, and a specificity of 84%. Measurement of peak systolic frequency ratios or end-diastolic frequencies had no additional diagnostic value for the detection of stenoses. The diagnosis of efferent vein stenoses was very accurate with duplex investigation (accuracy 96%, sensitivity 95%, and a specificity of 97%. We conclude that duplex scanning is a promising noninvasive method for the diagnosis of stenoses in arteriovenous fistulas created for hemodialysis access.     

Salvage of exposed arteriovenous hemodialysis fistulas

Arteriovenous fistulas constructed with an interposed segment of expanded polytetrafluoroethylene (PTFE) have been used successfully for long-term hemodialysis, but ultimately these fistulas may fail because of graft thrombosis, infection, or pseudoaneurysm. A PTFE graft may become exposed from skin necrosis at an area of repeated puncture for hemodialysis or from wound breakdown at a site of thrombectomy. Removal of an exposed PTFE graft has heretofore been considered inevitable, especially if a suture line is involved, because of the risk of hemorrhage and infection. We describe coverage of an exposed graft by a simple full-thickness skin flap that is locally rotated and report the successful salvage of five fistulas by this technique. Thus the concept that an exposed graft is infected and must be removed may not always be correct.     

Distal arteriovenous fistulas in elderly hemodialysis patients

Dialysis access procedures and complications are an important cause of morbidity and hospitalization for chronic hemodialysis patients. Subjects over 65 years old have a higher incidence of co-morbid factors (diabetes mellitus, atheros clerosis, neoplasms, heart failure), therefore the correct choice in terms of timing and type of permanent access is extremely important. As elbow fistulas are often complicated by heart failure and PTFE grafts have a higher risk of thrombosis, we decided to evaluate the success rate of distal fistula as primary dialysis access in elderly patients. We carried out a retrospective study to identify survival predictors and actual vascular network saving. Between January 1991 and September 2000, 277 vascular access procedures were performed on 198 elderly patients (age 65 or older). The first anastomosis was positioned as peripherally as possible. In cases of patients with poor peripheral vasculature or three co-morbid factors, vascular access was first created at the origin of radial artery (Toledo-Pereyra fistula). Survival (Kaplan - Meyer analysis) was significantly higher for Toledo-Pereyra fistulas compared to wrist and snuff-box ones, in spite of the presence of a high incidence of co-morbid factors. We conclude that Toledo-Pereyra fistula is an efficient primary choice in elderly patients.