Massive upper extremity edema following vascular access surgery

We recently treated three patients with chronic renal failure who required subclavian vein cannulation with Uldall catheters following thrombosis of their arteriovenous fistulae. New arteriovenous fistulae were created in each patient following removal of the Uldall catheters. The patients were seen subsequently with massive, painful edema in the ipsilateral upper extremities from one to 10 weeks following creation of the arteriovenous fistulae. Radiographic studies documented stenosis or occlusion of the ipsilateral proximal subclavian vein. The arteriovenous fistula was ultimately ligated in each patient, which promptly resolved the pain and edema. Because subclavian vein thrombosis following temporary hemodialysis through an indwelling catheter is frequently asymptomatic until an arteriovenous fistula is constructed, venography should be considered in patients requiring upper extremity vascular access procedures. Demonstration of subclavian vein stenosis or occlusion would either preclude use of the upper extremity for an arteriovenous fistula or would require a concomitant procedure to relieve the venous obstruction.     

Thrombotic arm edema as a complication of subclavian vein catheterization and arteriovenous fistula formation for hemodialysis

We report a case of persistent tense edema of the upper extremity following the surgical creation of an arteriovenous fistula for hemodialysis access. This was the result of poor venous return secondary to thrombosis of the subclavian vein. The thrombosis occurred after previous subclavian vein cannulation for hemodialysis.     

Identification of an arteriovenous fistula during free tissue transfer despite negative preoperative angiography: a potentially correctable cause of venous thrombosis

Although refinements in microvascular technique have resulted in great success with free tissue transfer, long-term anastomotic patency, particularly venous, is less predictable in patients with a history of intravenous drug abuse or other causes of intimal damage and/or venous hypertension. We report an unusual case in which an arteriovenous fistula was identified intraoperatively as the cause of pulsatile venous backflow despite a normal preoperative angiogram. A flow disturbance at the site of venous anastomosis and subsequent development of a venous thrombosis prompted more proximal venous exposure and the identification of an arteriovenous fistula. Once ligated, pulsatile venous backflow resolved and successful revision of the venous anastomosis was performed. This case illustrates that an anomalous arteriovenous communication must be considered when high-pressure venous backflow is observed intraoperatively, despite no evidence of an arteriovenous fistula on preoperative angiography, because, if identified and ligated, an arteriovenous fistula may represent a treatable cause of venous thrombosis. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:72-75 1998     

An unusual cause of venous hypertension after dialysis access creation

Venous hypertension after creation of arteriovenous fistula or arteriovenous shunt occurs in approximately 10-15% of patients (Kojecky et?al., Biomed Papers, 2002;146:77-79; Criado et?al., Ann Vasc Surg 1994;8:530-535). Its etiology is commonly stenosis and/or thrombosis of the central venous system secondary to previous catheterization with subsequent development of venous hypertension after the arteriovenous connection is made. Treatment strategies often involve venography to determine the site of venous stenosis and/or occlusion centrally and subsequent endovascular recanalization of the stenotic or occluded veins. In this article, we report a case of venous hypertension in a 76-year-old man who presented with a swollen arm after placement of an arteriovenous fistula. In this circumstance, venography revealed extrinsic compression of the subclavian vein at the level of the first rib, the anatomic abnormality seen in venous thoracic outlet syndrome. In this report, we describe surgical and endovascular management of this patient, and review the literature on the causes of central vein stenosis discovered after creation of dialysis access.     

Obesity is not an obstacle for successful autogenous arteriovenous fistula creation in haemodialysis.

BACKGROUND: Obesity, which is often associated with diabetes, is increasingly encountered in the haemodialysed population, and this may produce difficulty in autogenous arteriovenous fistula creation. Prosthetic angioaccess or catheters, when used in place of autogenous fistulas, increase thrombotic and infectious complications in these already challenged patients. METHODS: This prospective study was undertaken to assess the feasibility of autogenous arteriovenous fistula creation in 71 obese patients (BMI 34.6 +/- 7.8). We performed a two-stage procedure, in which radio-cephalic fistula formation was followed by subcutaneous transposition of the venous component for safe and easy puncture. RESULTS: Fistulas suitable for puncture, having blood flows of 799 +/- 285 ml/min, and sufficient to perform adequate haemodialysis (Kt/V 1.24) were achieved in 85% of the patients. Primary patency rates were 65% and 59% at 6 and 12 months, respectively, and secondary patency rates were 83% both at 6 and 12 months. CONCLUSIONS: Obesity does not prevent successful autogenous arteriovenous fistula formation, and may protect forearm venous vessels from the iatrogenic damage that occurs before the onset of haemodialysis therapy.     

Chronic venous congestion following embolization of spinal dural arteriovenous fistula

The authors present a case of spinal dural arteriovenous fistula with fluctuations in symptoms following embolization. Superselective injection of 33% N-butyl cyanoacrylate into the feeding vessel resulted in the complete occlusion of the fistula with traversal of the nidus. The subsequent venous congestion was progressive and treatable with anti-thrombin therapy. Extended medication with dual antiplatelet therapy was required because dose reduction to aspirin monotherapy worsened symptoms. In this case, it took > 2 months for the patient's symptoms to stabilize. The duration of progressive venous thrombosis after embolization of a spinal dural arteriovenous fistula is not well known, nor is the most adequate treatment. Although it is presumed that prevention of venous thrombosis is best achieved with anticoagulation, dual antiplatelet therapy can be a substitute for patients with poor compliance.     

Is AV fistula patency associated with angiotensin-converting enzyme (ACE) polymorphism and ACE inhibitor intake?

BACKGROUND/AIMS: Hemodialysis treatment requires a well-functioning vascular access. Access patency is limited by the development of venous intimal hyperplasia, which predisposes to fistula stenosis and subsequent thrombosis. In animal models, the renin-angiotensin system has a major role in the development of intimal hyperplasia. We investigated the association of the insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE) and arteriovenous fistula patency in hemodialysis patients. METHODS: In a longitudinal study, 137 hemodialysis patients who had undergone creation of a primary AV fistula were genotyped. The main study endpoint was unassisted access patency (time from fistula placement to the first episode of access failure). In addition, the intake of drugs blocking the renin-angiotensin system was assessed. RESULTS: Fistula patency 12 months after fistula creation was 72% (DD patients), 65% (ID patients), and 73% (II patients; p = 0.40). Long-term intake of ACE inhibitors or AT-1 antagonists failed to increase fistula patency (p = 0.33). CONCLUSIONS: We suggest that pharmacological inhibition of the renin-angiotensin system is of limited value for prevention of arteriovenous fistula stenosis. Alternative strategies to prolong fistula patency should be studied.     

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.     

Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula

Until recently, secondary thrombosis of the deep veins of the upper extremity was rarely encountered. The expanding use of the subclavian vein as a route to the central circulation has increased its occurrence, but symptoms are uncommon. Patients on hemodialysis with a functioning arteriovenous fistula become symptomatic with venous hypertension and swelling. Treatment becomes necessary, and fistula ligation is usually recommended; however, this renders the extremity unsuitable for a future life-sustaining access. Patency of grafts in the venous system has been accomplished with a temporary arteriovenous fistula. In six patients with chronic renal failure and a functioning arteriovenous fistula, a polytetrafluoroethylene graft was used to replace or bypass the obstructed vein. Symptoms resolved, and the fistula was preserved in three of the six patients for 1 to 3 years.     

The effect of arteriovenous fistulas on in situ saphenous vein bypasses

Intraoperative identification and later development of arteriovenous fistulas were investigated prospectively in 70 in situ saphenous vein bypass procedures. Surveillance was performed by completion arteriography and intra- and postoperative continuous wave Doppler examination. The intraoperative Doppler examination identified 89% of those branches with sufficient flow to opacify the deep venous system on completion arteriogram. Half of the missed fistulas underwent spontaneous thrombosis, and in only one case did the arteriovenous fistula lead to hemodynamic symptoms demanding surgical closure of the fistula. Pursuing a policy of selectively ligating fistulas that only fill the deep venous system on completion arteriography led to an additional nine arteriovenous fistulas. Developed over an average follow-up of six months, four patients presented symptoms of edema and swelling and were relieved upon closure of the fistulas. The incidence of bypass thrombosis did not differ significantly among patients with remaining arteriovenous fistulas, patients who developed fistulas during follow-up, and patients who had no signs of arteriovenous fistulas. It seems justified to continue selective intraoperative ligation of arteriovenous fistulas based on continuous wave Doppler.     

Posttraumatic arteriovenous fistula and subclavian vein thrombosis: Treatment by percutaneous arterial embolization and vein angioplasty

A 71-year-old woman had edema and venous dilatation of her upper right limb that caused painful functional disability following a shoulder injury. Arteriograms demonstrated an arteriovenous fistula between the subclavian artery and vein associated with thrombosis of the vein at the same level. The arteriovenous fistula was found to have multiple arteriovenous communications. Because of associated distal venous thrombosis, venous drainage was retrograde through the brachial vein. The inflow arteries of the fistula were embolized and then the subclavian vein thrombosis was recanalized, dilated, and an endoluminal stent inserted. Clinical signs completely resolved.     

Clopidogrel decreases arteriovenous fistula thrombosis but does not improve fistula maturation

This Practice Point commentary discusses Dember et al.'s randomized, double-blind, placebo-controlled trial of clopidogrel treatment after the creation of an arteriovenous fistula for dialysis. In total, 877 patients were treated with either placebo or clopidogrel (300 mg loading dose followed by 75 mg daily) for 6 weeks after fistula creation. Treatment with clopidogrel was associated with a significantly lower rate of fistula thrombosis than was placebo (12.2% vs 19.5%; P = 0.018). This reduction did not, however, lead to any changes in the secondary end point of attaining a useable access for dialysis; therefore, routine treatment with clopidogrel after fistula creation was not of clinical benefit in this well-conducted trial.     

Hemodynamics of an anastomotic arteriovenous fistula

Various vascular surgical techniques have been employed to increase both graft patency and limb survival when the prognosis for limb salvage in arteriosclerotic patients is especially poor due to a diseased outflow tract. Ibrahim et al described the creation of an anastomotic arteriovenous fistula in distal tibial bypasses as the reconstructive procedure of choice in severely ischemic extremities unsalvageable by more conventional methods. This study presents the hemodynamics of an anastomotic arteriovenous fistula under such circumstances. Four adult mongrel dogs were anesthesized, and a femoral artery and vein were exposed from the groin to the knee. The femoral artery was ligated in midthigh, and the ligated segment was than bypassed using an umbilical vein graft. The distal anastomosis included an arteriovenous fistula. Flow was measured electromagnetically, and pressure was measured with intravascular catheters attached to strain gauges. The creation of an anastomotic arteriovenous fistula rapidly leads to a reversal of flow in the distal artery, distal arterial hypotension, and distal venous hypertension. Its clinical use in contraindicated as a result of our experimental observations.     

Arteriovenous fistula for long-term venous access for boys with hemophilia

OBJECTIVES: Hemophilia is a sex-linked condition affecting about 1 of every 5000 males in the United States. The management of children with hemophilia can be improved with regular intravenous infusion of factor VIII or IX, thus preventing crippling and sometimes fatal hemorrhage. Maintaining this vital intravenous access is often hampered by gradual loss of superficial veins or repeated central catheter sepsis and thrombosis. This study reviewed an experience with arteriovenous fistula in selected hemophilia patients with limited venous access. METHODS: Consecutive patients operated on between October 2000 and July 2006 for venous access with the creation of an arteriovenous fistula were reviewed. They were selected because of repeated problems with other venous access. Patency, ease of use, duplex scan derived brachial artery diameter, and arm length were assessed. RESULTS: During a 69-month period, 10 arteriovenous fistulas (five brachial artery-basilic vein fistulas, 5 brachial artery-cephalic vein fistulas) were created for nine patients. The patients were a median age of 5.5 years (range, 1 to 27 years), and all were <13 except the 27-year-old patient. There were no postoperative hematomas requiring evacuation. One arteriovenous fistula failed to mature and was redone in the opposite arm, which subsequently occluded after 13 months. Of the mature fistulas, patency was 100% at 1 year, 80% (4/5) at 3 years, and 75% (3/4) at 4 years, with mean follow-up of 22 months. Brachial artery diameter increased in the involved arm by a ratio of 1.95 (range, 1.51 to 2.5) compared with the opposite arm. Arm length disparity was increased by 0.5 cm (range, 0.8 to 1.5 cm) in the involved arm. All fistulas allowed good access at home by a care provider. CONCLUSIONS: For hemophilia patients with compromised venous access, arteriovenous fistulas provide good early patency. Brachial artery diameter and arm length require continued follow-up.     

Intermittent claudication of the hand after creation of an arteriovenous fistula in the forearm

Eighty-five patients were followed up at least 1 year after creation of an arteriovenous fistula in the forearm. The anastomosis was side-to-side in 33 patients, end-to-side in 33 and end-to-end in 19. Trophic lesions were not observed. Intermittent claudication of the hand was more frequent in patients with a side-to-side arteriovenous fistula (42 percent) than in those with end-to-side (21 percent) or end-to-end fistulas (16 percent). Clinical and x-ray studies indicate that two different mechanisms are responsible for cramping pains: arterial steal phenomenon and venous hypertension. Their relative importance depends on multiple hemodynamic factors that may vary with time.     

Arteriovenous fistula using transposed basilic vein in chronic hypotensive hemodialysis patients

AIM: Chronic hypotension is not uncommon in uremic patients on regular hemodialysis. This subset of patients often requires multiple operations to maintain their vascular access due to frequent thrombosis and occlusion of the arteriovenous fistula. Our aims was to assess whether surgical intervention with the brachial artery-transposed basilic vein fistula is effective in chronic hypotensive hemodialysis patients. MATERIALS AND METHODS: Fifty-four hemodialysis patients with chronic hypotension were enrolled in this study. Most ofthem were referred from local hospitals. They were 23 men and 31 women. The brachial artery-transposed basilic vein arteriovenous fistula was performed in a period of 46 months at the teaching hospital. Primary patency was defined as the length of time from the fistula creation until the development of thrombosis or a complication that required operative revision ofthe fistula. Secondary patency was defined by whether the fistula could be salvaged by revision such that blood flow was maintained. RESULTS: There was no technical failure and none of these patients died due to the surgical operation. The primary patency rate was 89.80% at 1 year, 73.08% at 2 years, and 64.710% at 3 years. The secondary patency rate was 95.92% at 1 year, 84.62% at 2 years, and 76.47% at 3 years. CONCLUSIONS: Brachial artery-transposed basilic vein arteriovenous fistula may present good primary alternative vascular access in chronic hypotensive hemodialysis patients.     

Increasing the proportion of diabetics with AV fistulas

Worldwide, older diabetic patients represent the most rapidly growing group of patients treated for end-stage renal disease (ESRD). Preexisting arterial as well as venous problems have led to a pessimistic view on the creation of vascular access in this population. During 1993-98 I created all primary arteriovenous (AV) accesses for a total of 181 patients with diabetes mellitus (DM) ESRD and 567 patients with ESRD due to all other causes (non-DM). The following approach led to good outcomes for both groups whether assessed by time to first intervention or time to failure: careful preoperative investigations for selection of adequate location for initial AV fistula through ultrasonographic techniques; timely surgical AV fistula creation; preference of large-diameter, "healthy" arteries and veins, frequently requiring use of the elbow region; absolute priority for use of native vessels (i.e., avoidance of initial polytetrafluoroethylene [PTFE]); meticulous surgical technique and creativity; and continuous surveillance by the nephrologist and staff allowing elective revisions and avoidance of thrombosis. With this approach AV fistulas rather than PTFE grafts can be created in most diabetic and nondiabetic patients.     

Venous pressure monitoring does not accurately predict access failure in children

Access failure is a significant cause of morbidity and mortality in hemodialysis patients. Routine monitoring of arteriovenous (AV) fistulas and grafts could increase access longevity. Dynamic venous pressure monitoring is a surveillance test advocated to detect early signs of vascular thrombosis. Venous pressure measurements obtained, per DOQI recommendations, in children undergoing hemodialysis with an AV fistula or graft were reviewed. Baseline venous pressures were established by calculating the mean of venous pressures obtained without an antecedent thrombosis. A paired t-test was performed comparing mean baseline pressure measurements with pressures immediately preceding each thrombosis episode. Since some patients had multiple thrombosis episodes, the assumption of independence was not met. A second paired t-test was performed comparing mean baseline pressures with the mean pressure measurement per individual, obtained immediately preceding a thrombosis episode; 335 venous pressures were collected in ten pediatric patients. Eighteen thromboses occurred in five patients, in whom a total of 241 venous pressures were measured. Venous pressures did not correlate with thrombotic events ( P=0.4284). Specific thrombotic events for each patient were correlated with mean patient-specific venous pressures and showed no correlation ( P=0.3229). Dynamic venous pressure monitoring is not an adequate predictor of access thrombosis in pediatric patients.     

Results of surgical treatment for iliofemoral venous thrombosis

The long-term results after venous thrombectomy combined with a temporary arteriovenous fistula were evaluated in 19 patients. Clinical status, isotope phlebography, venous occlusion plethysmography and foot volumetry were performed after a mean follow-up time of 38 months (range 13-75). The primary operation was successful in 17 of the 19 patients; the 2 remaining had chronic occlusions of their iliac veins. At the time of closure of the arteriovenous fistula, i.e. 3 months after thrombectomy, 14 patients had a patent iliac vein. At follow-up eight patients were considered to have a patent iliac vein, eight had a partial restitution and three had an occluded iliac vein. The group as a whole had no impaired venous emptying of the leg, but the small group of patients with occlusion at follow-up according to isotope phlebography seemed to have an impaired venous emptying. Foot volumetry showed only minor signs of valvular insufficiency, mainly in limbs with distal extension of the initial thrombus or only partial restitution of venous patency. A good long-term result can be expected after venous thrombectomy with a temporary arteriovenous fistula particularly in younger patients where the thrombosis is limited to the iliofemoral segment. This emphasizes the importance of early operation before distal extension of the thrombus occurs.     

The influence of atherosclerosis and plasma D-dimer concentration in patients with a functioning arteriovenous fistula for maintenance hemodialysis

Objective The aim of this study was to deduce the influence of atherosclerosis and plasma D-dimer concentration on the functioning of arteriovenous fistulae for hemodialysis. Methods The study was organized as a prospective and non-randomized investigation in the “Kragujevac” Clinical Center. The 81 examined patients, 49 (60.5%) males and 32 (39.5%) females, were divided into a group (n = 36) requiring several attempts to create arteriovenous fistulae for hemodialysis and a group (n = 45) with no complications of arteriovenous fistulae for hemodialysis. The demographic structure, etiology of renal disease, biochemical parameters and concentration of D-dimer were analyzed at the beginning of the study and 1 year later, as well as the existence of tissue calcification and Duplex ultrasound parameters of the carotid artery. Results The patients with arteriovenous fistulae complications were significantly older (58.4 ± 12.9 vs. 52.3 ± 11.6 years; P = 0.026). High venous pressure (98.6 ± 29.98 vs. 80 ± 33.57 mmHg; P = 0.005) and soft-tissue calcification (P = 0.03) were correlated with the occurrence of arteriovenous fistula complications. The greatest risk for failure of fistula was within the first month after creation of the anastomosis (failure rate was 0.235). The hemoglobin concentration (89 ± 14.0 vs. 96.6 ± 17.7 g/l; P = 0.048) was lower, and concentration of D-dimer at the end of the study was higher (219.56 ± 193.05 vs. 332.03 ± 149.48; P = 0.012) in patients with vascular access complications. By Cox regression analysis, the concentration of fibrin D-dimer at the end of the study was shown to be a significant predictor of fistula survival (β = 0.002; P = 0.006). Conclusions Complications of arteriovenous fistulae were more often recorded in older patients. The greatest risk for fistula functioning was within the first month after creation of the anastomosis. Vein pressure and anemia were important indicators of arteriovenous fistula complications. D-dimer was a significant marker of arteriovenous fistula thrombosis.