The modified bovine heterograft in vascular access for chronic hemodialysis.

The results of 100 modified bovine heterografts constructed in 93 patients for subcutaneous arteriovenous fistulas for chronic hemodialysis have been reviewed. Fifty-seven patients had the bovine heterograft inserted as the primary method of vascular access. Twenty-eight patients had complications consisting of graft thrombosis and stenosis, graft infection, and hemorrhage that required additional surgical procedures. Three patients with diabetes mellitus developed ischemia of the hand. Fourteen patients have died but none of the deaths could be attributable to the use of the bovine heterograft. In our experience the modified bovine heterograft has enjoyed a higher patient acceptance as compared to other methods of vascular access for hemodialysis. The chief advantage of the bovine graft has been the ability to use the graft in any patient as a means of immediate dialysis.     

Vascular access for chronic hemodialysis using modified bovine arterial graft arteriovenous fistula

Modified bovine arterial graft arteriovenous fistulas were used for access to the circulation for hemodialysis in thirty-six patients whose forearm vessels were unsuitable for Brescia-Cimino fistulas. Twenty-seven of thirty-one thigh fistulas and three of five forearm fistulas are still functioning well. Most of the complications were minor and may be preventable. Thigh heterografts provided excellent blood flow for dialysis and have been the most successful alternative for patients who have repeated shunt or fistula failures.     

Experience with central high flow arteriovenous fistulas in patients requiring chronic parenteral chemotherapy or hemodialysis

Fifty central high flow arteriovenous fistulas were constructed using bovine arterial heterograft during the past four years to provide vascular access in forty-four patients requiring cyclic infusion chemotherapy or chronic hemodialysis. Overall long-term patency of thirty-six axillary-axillary and fourteen axillary-internal jugular fistulas was approximately 80 per cent, and of those fistulas that failed, 87 per cent were successfully revised. All failures occurred within the first year after construction and were confined to the group of patients receiving cyclic infusion chemotherapy. Most of the failures could be directly related to constant rather than intermittent use of the fistulas. Complications other than graft occlusion occurred in three patients and prompted surgical intervention—in one patient for brachial artery thrombosis, in one for unilateral facial edema after axillary-internal jugular fistula, and in one for aneurysmal degeneration of the midsegment of one axillary-axillary graft. There was no operative mortality, and there were no septic, hemorrhagic, or significant wound healing complications in this high risk group of patients. Hemodynamic evaluations of both acute and chronic fistulas showed an approximate 20 per cent increase in cardiac output, cardiac index, and right ventricular stroke work index which were subjectively and objectively well tolerated in those patients studied. Ease and comfort of cannulation of these fistulas for blood sampling, infusion chemotherapy, and hemodialysis were uniformly acceptable to both nurses and patients.Central high flow arteriovenous fistulas have proved a safe, durable, well tolerated means of providing vascular access in patients whose usual routes have been exhausted but who remain candidates for cyclic infusion chemotherapy or chronic hemodialysis.     

Arteriovenous PTFE Dialysis Access in the Lower Extremity: A New Approach

Advances in hemodialysis technology have allowed application of this treatment modality to an ever-increasing number of patients. Maintaining patients on dialysis for more than a decade is not unusual and the treatment of such patients may be limited primarily by the availability of vascular access. The aim of this study was to assess the efficacy and safety of a PTFE bridge graft between the superficial femoral artery and vein when more conventional arteriovenous fistulas cannot be accomplished. Use of the lower extremity had previously been avoided because of a greatly increased risk of infection. Over the period October 1, 1992 to March 31, 1997, we performed 14 of these grafts in 11 patients (6 men and 5 women) whose median age was 56 (range 34-85) years. The patients were on long-term hemodialysis and vascular access in the upper extremity was not possible. The median time from start of hemodialysis to receiving a suprapatellary bridge graft was 8 months (range 0-67). The suprapatellary graft was performed on two patients who were just starting on hemodialysis. Six patients received PTFE prosthetic implants in both arms and the other three patients underwent both native arteriovenous fistulas and PTFE prosthetic implants in the arm before the thigh was used. Only one patient had diabetes mellitus. Primary patency at 1 year was 54% and at 2 years, 18%. Secondary patency at 1 year was 64% and at 2 years, 18%. A PTFE bridge graft between the superficial femoral artery and vein for hemodialysis is a promising alternative when upper extremity arteriovenous fistulas cannot be constructed. The procedure is easily and rapidly performed with good access, and the patient clientele is easily selected. The technique has not been described previously.     

Human umbilical cord vein allograft arteriovenous fistula for chemotherapy access.

Seven patients who received chronic chemotherapy and required vascular access underwent construction of an arteriovenous fistula of the leg using gluteraldehyde-tanned human umbilical cord vein allografts. No wound or graft complications have occurred and patient tolerance of the operative procedure and subsequent use of the fisulas for chemotherapy has been excellent. Our preliminary results suggest that the use of umbilical vein allograft arteriovenous fistulas is quite satisfactory for long-term chemotherapy access.     

Venous aneurysm following construction of a polytetrafluoroethylene arteriovenous dialysis graft

Expanded polytetrafluoroethylene (ePTFE) is the most commonly employed vascular prosthetic for constructing arteriovenous fistulas for hemodialysis. Venous aneurysm is a rare complication following construction of such fistulas. We describe the case of a saccular aneurysm of the cephalic vein arising after construction of a PTFE arteriovenous graft for hemodialysis. The aneurysm was successfully resected with primary repair of the vein, allowing continued use of the graft for dialysis.     

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.     

Prosthetic arteriovenous fistula for vascular access in hemodialysis.

Vascular access through subcutaneous prosthetic arteriovenous fistulas was studied in eighteen dogs. Dacron velour and woven Dacron grafts (6 mm diameter) were constructed across the lower abdomen between the common femoral artery and the opposite common femoral vein. In heparinized animals 197 percutaneous punctures were made with a "14 guage hemodialysis cannula at weekly intervals. Over a period of one and a half years there was no instance of infection. One of the fourteen Dacron velous and all four woven Dacron fistulas thrombosed. These data suggested the feasibility of achieving repetitive blood access through Dacron velour vascular prostheses. Nineteen Dacron velour fistula bypasses between the brachial artery and median basilic vein were performed in fifteen selected patients for a total dialysis period of ninety-six months. Failed standard subcutaneous fistulas or absence of suitable vessels in the upper extremity were indications for the primary procedure. Of three looped forearm fistulas, two thrombosed at twenty-two and two months. Complications among sixteen straight bypasses in the arm included two graft infections and one cannula tract infection. There were no instances of thrombosis in this group. The advantages of single needle dialysis in these high risk patients have been emphasized. Eleven grafts are presently functioning two to nine months postoperatively. Our preliminary results suggest that a Dacron velour fistula merits consideration as an alternative for vascular access in maintenance hemodialysis.     

A synthetic vascular conduit (expanded PTFE) for hemodialysis access--a preliminary report

The short term follow up of the thirteen PTFE synthetic grafts placed in eleven patients for chronic hemodialysis is reported. PTFE graft appears to be a satisfactory alternative to a bovine graft for use as a subcutaneous arteriovenous conduit for hemodialysis. Its resistance to local infection is noteworthy.     

Axillary artery to contralateral axillary vein graft fistula in chronic hemodialysis patients

BACKGROUND: Vascular access failure is a severe and common complication for hemodialysis patients. The possible vascular access sites are limited in dialysis patients. Axillary artery to contralateral axillary vein arteriovenous fistula (AVF) is one of the possibilities. However, the clinical outcome of this procedure is still un-defined. OBJECT: The purpose of this study is to review the clinical outcome of axillary artery to contralateral axillary vein AVF as a hemodialysis vascular access. PATIENTS AND METHODS: We retrospectively reviewed native or graft arteriovenous fistula records for chronic hemodialysis patients at Chang Gung Memorial Hospital in Kaohsiung, Taiwan, from January 1986 to March 2001. Records were reviewed for all chronic hemodialysis patients, with more than 2000 individuals receiving more than 10,000 fistulas. Eight patients received axillary artery to contralateral axillary vein AVF. RESULTS: The mean age for these patients was 61.7 +/- 16.3 year-old at time of surgery. All patients had received multiple native or graft arteriovenous fistula creation. The 2-year and 4-year AVF graft survival is 87.5% and 43.8% respectively. One patients developed brachial plexopathy after operation. Another patient had venous hypertension distal to the AVF site. Both patients were managed conservatively. There is no AVF-related mortality in these patients. CONCLUSION: We conclude that axillary artery to contralateral axillary vein graft fistula may be a feasible alternative choice for chronic hemodialysis access.     

The axillary artery to axillary vein bovine graft for circulatory access: Surgical considerations

The bovine graft axillary artery to axillary vein fistula provides a simple method of circulatory access. This method is reserved for patients in whom Cimino arteriovenous fistulas or looped grafts have failed. The grafts are easy to cannulate, flow is excellent, and the patients adapt to it very promptly.     

Das arterioarterielle Interponat als Dialysezugang

We report on two patients who received arterio-arterial PTFE grafts as vascular access for chronic hemodialysis. In both patients prior surgery for arteriovenous fistulas using either subcutaneous veins or arteriovenous, artificial PTFE grafts had failed due to recurrent thrombosis and septic complications. The arterio-arterial grafts were each positioned as a subcutaneous loop on the thigh and anastomosed with the common femoral artery and the superficial femoral artery or the profunda femoris, respectively. Postoperatively, both patients received coumadine for anticoagulation. Nine months after surgery no complications were observed in the former patient. The latter patient experienced recurrent thrombotic occlusion of the graft and a new graft was required which was anastomosed end-by-end onto the common femoral artery. As yet, 5 months after the second operation, no further complications have been reported. In conclusion, in patients lacking suitable veins for arterio-venous anastomoses, artificial arterio-arterial grafts may provide vascular access for chronic hemodialysis.     

Infectious complications of prosthetic arteriovenous grafts for hemodialysis: prevention is better than cure

Synthetic arteriovenous grafts for hemodialysis constitute the second choice in comparison with native arteriovenous fistulas. Lower patency rates and significantly more frequent infections are the main disadvantages of hemodialysis grafts over fistulas. Infectious complications could vary between a simple local erythema at a puncture site that resolves easily with antibiotics to septicemia and death. As a corollary, this kind of complications continue to be among the most important causes of morbidity and mortality in end-stage renal disease patients receiving long-term hemodialysis. The cornerstone is prevention of infections. It is generally accepted that following simple measures during the intervention of graft insertion and consecutively in every hemodialysis session could consistently reduce the risk of infection.     

Axillary Artery to Contralateral Axillary Vein Graft Fistula in Chronic Hemodialysis Patients

Background.?Vascular access failure is a severe and common complication for hemodialysis patients. The possible vascular access sites are limited in dialysis patients. Axillary artery to contralateral axillary vein arteriovenous fistula (AVF) is one of the possibilities. However, the clinical outcome of this procedure is still un-defined. Object.?The purpose of this study is to review the clinical outcome of axillary artery to contralateral axillary vein AVF as a hemodialysis vascular access. Patients and Methods.?We retrospectively reviewed native or graft arteriovenous fistula records for chronic hemodialysis patients at Chang Gung Memorial Hospital in Kaohsiung, Taiwan, from 01 1986 to 03 2001. Records were reviewed for all chronic hemodialysis patients, with more than 2000 individuals receiving more than 10,000 fistulas. Eight patients received axillary artery to contralateral axillary vein AVF. Results.?The mean age for these patients was 61.7 ± 16.3 year-old at time of surgery. All patients had received multiple native or graft arteriovenous fistula creation. The 2-year and 4-year AVF graft survival is 87.5% and 43.8% respectively. One patients developed brachial plexopathy after operation. Another patient had venous hypertension distal to the AVF site. Both patients were managed conservatively. There is no AVF-related mortality in these patients. Conclusion. We conclude that axillary artery to contralateral axillary vein graft fistula may be a feasible alternative choice for chronic hemodialysis access.     

Innovationen von Dialyseshuntprothesen

Autologous arteriovenous fistulas are the gold standard in vascular access surgery for hemodialysis. When autologous options have been exhausted, prosthetic arteriovenous grafts play an important role for creating a permanent vascular access. Changes in design and material technology used in graft manufacture are helping to improve graft performance and longevity. This article summarizes major developments in prosthetic grafts for vascular access. Supporting evidence from the literature is quoted when available. Most of the innovations, while promising, lack significant evidence-based support and this is also highlighted.     

Failure of arteriovenous fistula maturation: an unintended consequence of exceeding dialysis outcome quality Initiative guidelines for hemodialysis access

PURPOSE: The Dialysis Outcome Quality Initiative (DOQI) guidelines recommend that arteriovenous fistulas (AVF) be constructed in at least 50% of hemodialysis access procedures. Preoperative duplex ultrasound (US) scanning and venography may increase options for AVF with identification of veins that are not clinically evident. However, maturation of autogenous fistulas created on the basis of findings at duplex US scanning and venography has not been carefully examined. METHODS: From January 1999 to July 2002, 256 new hemodialysis access procedures were performed in 202 patients in an academic tertiary care center. If physical examination failed to disclose adequate vessels for hemodialysis access, patients underwent duplex US scanning mapping. Venography was performed when no usable vein or only a basilic vein was identified at duplex US scanning. Functional maturation rate and mean maturation time (time from fistula creation to initiation of hemodialysis) were determined. This experience was compared with that in a group of 128 patients in whom 148 hemodialysis access fistulas were created before we implemented liberal use of preoperative duplex US scanning and venography (January 1997-December 1998). RESULTS: From January 1999 to July 2002, preoperative duplex US scanning was performed in 68% of patients, and venography in 32% of patients. Autogenous fistula creation rate increased from 61% to 73% in all patients with hemodialysis access fistulas (P =.15) and from 66% to 83% in patients undergoing a first access procedure (P <.05). The use of basilic vein transposition also increased, from 3% in the earlier period to 13% in the later period (P <.05). Mean maturation time for arteriovenous fistulas was 70 days. Functional maturation rate decreased from 73% to 57% (P <.05) after implementation of preoperative imaging and more aggressive vein use. CONCLUSION: Implementation of preoperative duplex US scanning and venography as a component of a more aggressive protocol to create native fistulas was pivotal in exceeding DOQI guidelines for hemodialysis access. However, this approach resulted in the unintended sequela of decreased fistula maturation rate. Our experience suggests that improved selection criteria based on findings at preoperative imaging are needed to further refine and optimize arteriovenous access surgery.     

Immediate use of an arteriovenous prosthetic graft for life-saving dialysis in a child

Background

Autologous arteriovenous fistulas (AVFs) are the current gold standard for vascular access in hemodialysis (HD). However, in pediatric patients, specific clinical settings may contraindicate the procedure, thus mandating the use of a prosthetic graft (PG).

Case-Diagnosis/Treatment

We report a case of successful polycarbonate urethane graft implantation and subsequent resumption of HD 12?h after the procedure in a young girl with end-stage renal disease (ESRD), challenging vascular anatomy and the absence of vascular access.

Conclusions

The use of polycarbonate urethane PGs in children with ESRD and difficult vascular accesses may represent a valid alternative for early resumption of HD.     

Brachial-jugular polytetrafluoroethylene fistulas for hemodialysis

A retrospective analysis was made of 16 patients who had received a brachial-jugular polytetrafluoroethylene (PTFE) graft for hemodialysis. In four patients, the procedure was used to treat malfunctioning brachio-axillary fistulas due to long venous stenosis in the axillary vein. In 12 other patients, the operation was chosen in cases of exhaustion of the veins in the upper extremity because of previous multiple failed fistulas. Two patients died with a functioning fistula 7 and 10 months after placement of the graft of causes unrelated to the vascular access. The other 14 patients retained functioning fistulas between 8 and 26 months after construction of the shunt. Three patients needed graft thrombectomy to treat occlusive episodes. No venous stenosis was found in a postoperative fistulography made in those patients. One patient needed substitution of a graft segment due to stenosis of the prosthesis crossing over the clavicle. We believe that the brachial-jugular graft is a procedure that can be considered as vascular access for hemodialysis in cases where the use of veins in the upper extremity and the axilla is not possible.