The Impact of Arteriovenous Fistulae for Hemodialysis on the Cardiovascular System

An arteriovenous fistula (AVF) is critical for the provision of optimal chronic hemodialysis. Its creation causes significant hemodynamic alterations in cardiovascular parameters, and can result in progressive left and right heart failure. Despite successful kidney transplantation, many patients retain a functional AVF indefinitely, which may contribute to ongoing adverse cardiovascular outcomes. A similar high risk:benefit ratio may exist in peritoneal dialysis patients with “backup” AVF.     

Do Distal Arteriovenous Fistulae Improve Patency Rates of Prosthetic Infrapopliteal Arterial Bypasses?

p > 0.05). There were statistically significant differences in the site of distal anastomosis and quality of arterial run-off based on the Society for Vascular Surgery Ad Hoc Committee on Reporting Standards criteria (p < 0.05). All patients were placed on heparin 500 units/hour postoperatively, maintained on life-long Coumadin and followed every 3 months with duplex ultrasonography to assess graft patency. Aggressive intervention was carried out for failing grafts suspected by duplex scanning. The hospital mortality rate was 2.3% (1/43; 1 PTFE-AVF). Two-year primary patency rates were significantly better for PTFE-AVF grafts than for PTFE-ONLY grafts (23% versus 5%) (p= 0.04). Although statistical significance was not reached, there was a suggestion of higher assisted primary (34% versus 15%) (p > 0.05) and secondary (61% versus 48%) (p > 0.05) patency rates in the PTFE-AVF group versus the PTFE-ONLY group, although limb salvage rates were similar (74% versus 71%) (p > 0.05). Two AVFs required ligation because of steal resulting in diminished distal perfusion. These results support the use of adjunctive distal AVFs to improve overall two-year patency rates of prosthetic infrapopliteal arterial bypasses.     

Patency Rates of Portal Vein/Superior Mesenteric Vein Reconstruction After Pancreatectomy for Pancreatic Cancer

Background

Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction.

Methods

From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up.

Results

VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16 %) or saphenous vein patch (9, 21 %); segmental resection with splenic vein division and either primary anastomosis (10, 23 %) or internal jugular vein interposition (8, 19 %); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7 %) or interposition grafting (6, 14 %). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9 %) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16–238).

Conclusions

Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.     

Arteriovenous Fistula as a Complication of Percutaneous Femoral Vein Catheterization for Hemodialysis

Sudden onset of congestive heart failure due to development of a femoral arteriovenous fistula in a hemodialysis patient is reported as a complication of repeated femoral vein catheterization for access. Closure of the fistula led to disappearance of signs and symptoms of congestive heart failure.     

Primary Arteriovenous Fistulas in the Forearm for Hemodialysis: Effect of Miscellaneous Factors in Fistula Patency

Background. The provision and maintenance of vascular access remains a major cost to end-stage renal failure programs. In addition, vascular access occlusion, results in significant morbidity in hemodialysis patients. Age, gender, diabetes mellitus, malignancy, smoking habits, administration of heparin per hemodialysis session, previous dialysis catheter insertion, number of hemodialysis sessions and location of the fistula may be associated with survival of the primary arteriovenous fistula. We examined the effects of various factors on fistulas in 412 chronic renal insufficiency patients. Methods. From 1995 to 2004, 412 arteriovenous fistulas were created by the Department of Cardiovascular Surgery at the Medical Faculty of Atatürk University for hemodialysis. The mean age of the patients was 45 years (range 6 to 62 years). We evaluated the effects of various factors for patency rates in the patients who had primary arteriovenous fistulas. Primary patency was defined as the duration of fistula patency without revision. Twenty-eight patients (6.7%) with ischemic cardiac disease did not require surgical interference. Analyzed data were age, gender, smoking habits, diabetes mellitus, malignant neoplasm, previous dialysis catheter insertion, number of hemodialysis sessions, and fistula location. Results. In 298 patients, where lower-arm radiocephalic fistulas were created, the fistula patency was 74.1%, 64.2%, 49.8%, 33.7%, and 4.1% after 1, 2, 3, 4, and 5 years, respectively, in the other 114 patients, where upper-arm fistulas were created, these rates were 84.0%, 72.2%, 53.3%, 39.8%, and 12.3%, respectively. There was no significantly difference between the upper-arm fistulas and the lower-arm fistulas statistically (p = 0.069). Factors affecting the primary patency of arteriovenous fistulas were diabetes mellitus (p = 0.0001), hemodialysis counts ≥3 per week (p < 0.0005), presence of malignancy (p < 0.0005), previous catheter insertion (p < 0.0007), and administration of heparin per hemodialysis session (p = 0.0008). Conclusion. While primary arteriovenous fistula patency was shortened in chronic renal insufficiency patients with diabetes mellitus, presence of malignancy, and previous catheter insertion, patency was longer in patients with heparin used for hemodialysis and hemodialysis count per week (≥3).     

Lateral Subfascial Endoscopic Perforating Vein Surgery as Treatment for Lateral Perforating Vein Incompetence and Venous Ulceration

Background  The aim of this study was to evaluate the clinical results of lateral subfascial endoscopic perforating vein surgery (SEPS). Methods  Our study was conducted from February 2002 to January 2007. Sixty-three patients with lateral incompetent perforating veins (IPVs) and venous ulceration were allocated to two groups. Group 1 comprised 31 patients (33 limbs) who underwent only routine surgery (saphenofemoral or saphenopopliteal ligation, stripping, phlebectomies, endovascular laser treatment [EVLT], medial SEPS, and skin grafting). Group 2 comprised 32 patients (35 limbs) who underwent our routine surgery with the addition of lateral SEPS. Bidirectional ultrasonography was performed before the operation, and 6 weeks, 6 months, and 1 year after surgery. Clinical score and disability score were collected at the same time. Results  Twenty-nine (87.9%) of 33 limbs with active ulcers in group 1 healed, with recurrence in four (12.1%) limbs at follow-up at 25.9 ± 10.0 months. All 35 limbs in group 2 healed, with recurrence in 0 (0.0%) limbs at follow-up at 25.4 ± 10.1 months. Lateral SEPS could reduce the rate of recurrence of ulcers (Kaplan–Meier analysis). Patients in group 2 also showed improvement in clinical and disability scores, although they were not statistically significant differences (t test, p > 0.05). A significantly higher proportion of patients in group 1 had IPVs on the lateral aspect of the lower leg on ultrosonography imaging. Conclusions  Lateral SEPS could contribute to ulcer healing and reduce ulcer recurrence. The addition of lateral SEPS to routine surgery did reduce the number of IPVs. Lateral SEPS may be safe and effective for lateral perforating vein incompetence and venous ulceration.     

Percutaneous Transluminal Angioplasty of Failing Arteriovenous Dialysis Fistulae

Percutaneous transluminal angioplasty (PTA), a method combiningdiagnostic and therapeutic procedures, was studied prospectivelyin 40 patients with clinically failing a-v fistulae. Forty-sevenprocedures were performed in 40 patients with a variety of a-vfistulae (26 Cimino, five saphenous loops, five goretex grafts,and four upper-arm fistulae). In 43 cases the procedure wasinitially successful. The mean time of fistula patency afterfirst PTA was 10.06±2.10 months. Primary failures weredue either to technical inability to pass the stenosis (twopatients) or to vessel perforation during the attempt (two patients).Surgical intervention had to follow both perforations. Restenosisat the dilatation site occurred in six patients, and in onea new stenosis at a different site occurred; the mean time offistula patency in these patients was 5.8 months. Our results suggest that PTA is a highly effective therapy forthe majority of cases of shunt stenosis. The success rate ofthe method is excellent and the complication rate low. The combinationof this interventional approach with the mandatory angiographicprocedure if stenosis of a fistula is suspected makes PTA afavourable first-line treatment and appears to save a considerablenumber of surgical interventions.     

Unmasking of Subclavian Vein Obstruction Following Creation of Arteriovenous Fistulae for Haemodialysis. A Problem Following Subclavian Line Dialysis?

We report three cases of subclavian vein obstruction followinghaemodialysis by a subclavian line. The obstruction only becameapparent clinically following the formation of an arteriovenousfistula on the same side as the initial catheterisation. Ineach case, gross swelling of the arm followed creation of thefistula. One case responded to treatment with anticoagulants,but the other two required ligation of the arteriovenous fistulawith rapid resolution of the swelling.     

Axillary Graft-Subclavian Venous Extension for Salvage of Graft Arteriovenous Fistulae

A technique for the salvage of looped forearm graft arteriovenous fistulae utilizing extension of the venous limb to the subclavian vein is described. Results have been excellent with extension of the functional life of the fistulae.