Subcutaneous brachial vein arteriovenous fistula for chronic hemodialysis

While the subcutaneous arteriovenous fistula is the ideal method for creating vascular access for chronic hemodialysis, it is not suitable for all patients. Other methods such as polytetrafluoroethylene grafts have proven satisfactory but have been fraught with problems in some cases. In these situations, we have employed the brachial vein arteriovenous fistula as a means of providing continuing vascular access. The brachial vein is dissected free from surrounding structures in the upper arm and anastomosed to the distal brachial artery in end-to-side fashion. The arterialized vein is then placed in the subcutaneous position for easy access. We have performed this procedure in 12 patients. All have had previous access problems. Follow-up has extended from 1 to 34 months. There have been 3 failures and 7 complications. Nine patients have maintained patency of their fistulas through the follow-up period, until transplanted, or until death. We feel that the brachial vein fistula is a reasonable alternative in patients who have encountered problems with standard wrist arteriovenous fistulas or with prosthetic grafts.     

Traumatic arteriovenous fistula of the brachial artery and vein

The fifty-second case of an aneurysm occurring on the coronary artery is reported. It is suggested that the aneurysms located at the bifurcation of the major branches of the coronary arteries develop as a result of a congenital defect which occurs in the media of the artery.The cases of aneurysms occurring on the coronary arteries previously reported are briefly reviewed. It appears that some of these may have developed as a result of a defect at the point of bifurcation of the coronary vessels. The location of some of these aneurysms in regard to the aorta and the branches of the coronaries is similar to that in our case.Etiological agents other than congenital defects may produce aneurysms in the coronary arteries.     

Comparison of basilic vein and polytetrafluoroethylene for brachial arteriovenous fistula

Purpose: The aim of this study was to compare patency and complication rates between basilic vein and polytetrafluoroethylene (PTFE) for brachial arteriovenous fistulas (AVF) for long-term hemodialysis.Methods: All basilic vein and PTFE brachial AVF constructed between March 1988 and April 1993 were retrospectively reviewed. After construction of life-tables, log-rank testing was used to compare the primary patency rate of basilic vein AVF (n = 59) with the primary and secondary patency rates of PTFE AVF (n = 47). Complication rates were calculated for each type of fistula and compared by use of chi-squared testing.Results: The primary patency rate for basilic vein AVF (90%) was superior to that of PTFE AVF (70%) at 1 year (p < 0.01), and at 2 years (86% vs 49%, p < 0.001). Complications occurred two and a half times more frequently in the PTFE group than in the basilic vein group (p < 0.05).Conclusions: Basilic vein AVF provided superior patency rates and lower complication rates compared with PTFE AVF. Prospective randomized trials comparing the two fistula types is required to firmly establish the basilic vein AVF as the alternative access procedure of choice after a failed or unconstructable radiocephalic fistula. (J VASC SURG 1994;20:896-904.)     

Evaluation of the brachial artery to brachial vein bovine heterograft arteriovenous fistula for hemodialysis.

The use of the bovine heterograft in the severely ill patient is reviewed. From personal experience and a review of the literature we believe the preferred site of placement is between the brachial artery and brachial vein in the arm.     

臂丛神经阻滞在动静脉内瘘成形术中的应用

目的观察臂丛神经阻滞在动静脉内瘘成形术中的效果。方法拟行动静脉内瘘成形术患者152例,随机均分为臂丛神经阻滞组和局部浸润麻醉组。臂丛神经阻滞组手术中采用臂丛神经阻滞法进行麻醉,局部浸润麻醉组术中给予局部浸润麻醉法。比较两组术中VAS疼痛评分、术中血管直径、术后4h内瘘血流量、手术时间、术后24h和术后2年的手术成功率及麻醉安全性。结果臂丛神经阻滞组VAS疼痛评分、手术时间明显低于局部浸润麻醉组(P0.01);臂丛神经阻滞组术中动脉直径、术中静脉直径和内瘘血流量明显高于局部浸润麻醉组(P0.01)。臂丛神经阻滞组术后24h手术成功率为98.68%,与局部浸润麻醉组的92.11%差异无统计学意义;但臂丛神经阻滞组术后2年手术成功率为88.16%,明显高于局部浸润麻醉组的75.00%(P0.05)。两组均未见明显药物不良反应。结论臂丛神经阻滞可减轻术中疼痛,提高动静脉内瘘成形术手术成功率。     

超声在动静脉内瘘并发症中的应用进展

动静脉内瘘(AVF)是终末期肾病患者最常用的透析通路,但在建立及透析过程中易出现各种并发症,常见者包括内瘘成熟障碍、内瘘狭窄及血栓形成等。早期发现AVF并发症并适当干预、保持通路畅通,可改善终末期肾病患者预后。超声检查可评估及辅助AVF成熟、早期发现AVF常见并发症并辅助介入治疗等。本文就超声在AVF并发症中的应用进展进行综述。     

Delayed treatment and late complications of a traumatic arteriovenous fistula

An 18-year-old soldier had a gunshot wound to his left thigh during the Mexican Civil War (1910-1917). He presented with persistent bright red bleeding. His wound was treated by compression. A few years after the injury, he noticed a thrill, large varicose veins, limb swelling, and skin changes. A plain film showed an 8 x 10-cm midthigh mass. After a bullfighting incident, the pseudoaneurysm ruptured. Because of increased bulk and discomfort, the patient agreed 3 years later to be treated. Angiography showed a chronically obstructed femoral artery and vein. A 3000-mL hematoma was evacuated. This case illustrates the long-term sequelae of an arteriovenous fistula. This report describes a 51-year delay of treatment for causes unrelated to diagnosis. To our knowledge, this case is the longest delay in treatment of an arteriovenous fistula and its complications reported in the literature.     

内瘘常见并发症的原因分析与护理

目的 探讨内瘘常见并发症的血管彩色多普勒超声检查及护理对策.方法 24例尿毒症患者在内瘘手术后、使用过程中出现并发症,对出现并发症的内瘘进行血管彩色多普勒超声检查,根据内瘘血管彩色多普勒超声检查结果和患者内瘘并发症的临床表现,重新评估患者内瘘功能,并进行相应处理.结果 12例患者出现局部血肿,3例出现短时血栓形成导致暂...     

Late complications of traumatic arteriovenous fistula. Case report and overview

Traumatic arteriovenous (AV) fistulas produce several profound pathophysiologic and structural changes in the circulatory dynamics of the vessels associated with the fistula. Most of the changes are reversible with surgery. However, in longstanding AV fistulas, irreversible degenerative changes occur in the arterial wall and result in dilatation and thrombosis. This can make late closure technically difficult. This report presents a case of peroneal AV fistula of 18 years duration. The diagnosis, management, and complications of long-standing AV fistulas are discussed.     

肺动静脉瘘的栓塞治疗和并发症的预防与对策

目的应用介入栓塞的方法治疗肺动静脉瘘,探讨栓塞治疗中并发症产生的应对对策。方法回顾性分析栓塞4例肺动静脉瘘诊治的临床资料。结果4例患者栓塞成功,其相应的临床症状及体征基本消失。1例多支供血的右肺动静脉瘘经2次栓塞封堵了供血动脉;1例右肺动静脉瘘栓塞中微钢圈脱落至左房,经股静脉入路行房间隔穿刺后取出。结论介入栓塞是治疗肺动静脉瘘的有效方法,操作得当可避免并发症的发生。     

血液透析动静脉瘘建立的策略和复杂情况的处理

血液透析指把肾功能衰竭患者的血液引出体外,经透析机交换后再回输到体内去,该通路被称为血管通路.血液透析与腹膜透析是肾功能衰竭患者赖以生存的两大替代治疗手段.血液透析的完成依赖良好的血管通路.1960年Quinton等将患者的肢体动静脉血管用聚四氟乙烯管(PTFE)在体外连接起来,首次建立动静脉外瘘.1966年Brescia及Cimino发明了自体动静脉内瘘,使血液透析技术进入了新的时代,目前仍是慢性肾衰竭患者最安全有效的血管通路.上世纪70年代开始试行移植血管内瘘.     

Brachiobasilic arteriovenous fistula: different surgical techniques and their effects on fistula patency and dialysis-related complications

OBJECTIVE: Easy access to the vascular system is vital in patients with chronic renal failure undergoing long-term hemodialysis. Such patients often require multiple operations, and options for secondary or tertiary access procedures become increasingly limited. Brachiobasilic arteriovenous fistula offers excellent access in such difficult cases and is increasingly preferred over prosthetic grafts. Many surgical techniques have been described to create such fistulas. The purpose of this study was to determine the difference in long-term patency and dialysis-related complications among various techniques. METHODS: Seventy brachiobasilic arteriovenous fistulas were constructed in 70 patients. This was the secondary or tertiary access in 88.6% of patients. The basilic vein was transposed in 30 patients and elevated in 40 patients; twenty veins were elevated with a one-stage technique, and 20 were elevated with a two-stage (delayed elevation) technique. RESULTS: The early failure rate was 5.7% in the entire group. Sixty-six fistulas (94.3%) were successfully used for dialysis. Mean follow-up was 25.8 months (range, 4-36 months). Four fistulas (5.7%) required additional procedures during follow-up, 2 in the transposed vein group and 2 in the elevated vein group. Cumulative secondary patency rate, measured with the Kaplan-Meier survival method, was 86.7%, 90%, and 84.2% at 1 year for the transposed, one-stage, and two-stage elevation procedures, respectively, compared with 82.8%, 70%, and 68.4% at 2 years. The difference was statistically nonsignificant. Forty-two complications developed in 29 (43.9%) fistulas. Thirteen fistulas (19.7%) had more than one complication. Twelve complications in 10 fistulas (35.7%) were recorded in the transposition group, 15 complications in 9 fistulas (47.4%) in the one-stage elevation group, and 15 complications in 10 fistulas (52.6%) in the two-stage elevation group. The total complication rate was higher in the elevated fistulas (71.4% vs 28.6%); the difference was statistically highly significant (P <.001). The most common complication was arm edema (21.2%; n = 14), followed by puncture site-related hematoma (16.7%; n = 11) and thrombosis (16.7%; n = 11). Hematoma was statistically more common (P <.05) in the elevated vein group (26.3% vs 3.6%). The difference in thrombosis between the transposition and elevation groups (23.7% vs 7.1%) was not significant. Hematoma preceded thrombosis in 63.7% (7 of 11) of the fistulas, and it was the major predisposing factor for fistula failure. Transposed vein was easier to manage by dialysis staff. All nurses were satisfied with the transposed veins, but only 53.3% were satisfied with the elevated veins; the difference was statistically highly significant (P <.001). CONCLUSION: Available techniques for creating brachiobasilic arteriovenous fistula are associated with good patency rate, and most related complications can be treated conservatively without loss of the fistula. Among the various procedures, transposition has a lower complication rate and is favored by the dialysis staff dealing with such fistulas.     

Postnephrectomy arteriovenous fistula

A new case of postnephrectomy arteriovenous fistula is reported. This is an uncommon acquired complication of a common surgical procedure. Clinical features, diagnostic procedures, surgical treatment and results are analysed and discussed. In this case, a direct communication between the right renal artery and the inferior vena cava was found.     

Spinal arteriovenous fistula

A 62-year-old male suddenly developed a severe paraparesis after epidural anaesthesia. He recovered gradually over the next few months. He had an acute relapse one year later and a selective spinal angiography showed a dural T8 arteriovenous fistula with large draining veins. Intravascular embolisation of the fistula produced immediate and sustained clinical improvement. The mechanism commonly held responsible for neurological disturbances in spinal dural arteriovenous fistulas is cord hypoxia secondary to venous hypertension. The 20-ml of local anaesthetic solution injected into a narrow spinal canal with osteophytosis may have caused further venous engorgement, cord hypoxia and acute neurological deficit.     

Haemodynamics of brachial arteriovenous fistula development

This study observes the development of brachial arteriovenous fistulae, and assesses methods of predicting potential usefulness for haemodialysis. Creation of an adequate brachial fistula causes significant changes in blood flow to the forearm and hand. A prospective study of fifteen consecutive patients undergoing brachial arteriovenous fistula formation for haemodialysis was undertaken. Clinical measurements and coloured flow Doppler measurements were performed pre operatively, immediately post operatively and at two and eight weeks after surgery. The morphology of the fistula was studied and the volume flow was measured. Digital pressure was measured pre and post exercise at each visit. Fourteen fistulae worked well by eight weeks. There was an immediate large increase in brachial artery blood flow and by two weeks all fistulae that went on to develop well had a brachial artery flow of more than 700 mls/minute. The cephalic vein mean diameter pre operatively was 2.39 mm and increased to 5.4 mm by two weeks post operatively. Fistulae with flows over 400 mls/minute at two weeks had a good outcome. There were significant differences in digital pressure after fistula formation (P (2) 0.05). Digital mean arterial pressure dropped from 118 mm Hg pre-operatively to 98 mm Hg post operatively, at rest, and 89 mm Hg after exercise. Four patients developed forearm/hand claudication on exercise or signs of distal ischaemia. Three of these were diabetic with calcified vessels. All patients with a suitable cephalic vein should have attempted fistula formation rather than recourse to use of a synthetic graft. In diabetics creating a shunt in an already marginally competent vascular tree exposes the pa-tient to risk of significant hand ischaemia.