DYING ARTERIOVENOUS FISTULAS - ALL IS NOT LOST YET!
AbstractBackground: The aim of this study was to see the efficacy of different surgical procedures performed for the salvage of failing arteriovenous fistulas. Study design: Prospective observational study. Study was conducted at Department of Vascular surgery, CMH Rawalpindi from 1st August 2017 to 31st December 2018 Methods: Those surgical procedures were included which were done for the AVFs that failed to mature due to stealing veins or developed complications like thrombosis, hematoma, pseudo or true aneurysm, steal syndrome, stenosis and venous hypertension. The procedures like stealing vein ligation, hematoma evacuation, thrombectomies, redo-anastomosis, pseudo aneurysm excision, aneurysmorrhaphies, excision of stenotic segment, RUDI for steal syndrome and central veno venous bypasses for central vein occlusion were assessed for their efficacy. Results: Sixty-two patients were included. 21 stealing veins were ligated, 15 for fistula maturation and 6 for venous hypertension. Twelve out of these 15 non-maturing AVFs, matured after ligation of stealing vein (80%). In case of reverse vein ligation for venous hypertension all the 6 patients showed reduction in their limb swelling (100%). Nine thrombectomies were performed, 7 were successful (78%). Nine patients presented with stenosis. In 3 patients with stenosis near the anastomotic site, a proximal AVF was formed. In 2 patients the stenotic segment was excised and end to end anastomosis was done. In 1 patient an interposing vein graft was used. In 3 patients, the flow was redirected to basilic vein. All the patients had patent AVF on follow up (100%). In 8 non-infected pseudo aneurysms, excision and end to end anastomosis was done in 3, aneurysmorrhaphies in 2 and revision of the anastomosis in 3 cases. Seven out of 8 (87.5%) had good patency on follow up. In 7 patients with true aneurysm and 3 with bleeding from needle prick site sinus, aneurysmorrhaphies were performed. Two wound site hematomas were evacuated. Two patients presented with severe limb swelling due to central venous occlusion for whom a veno venous cross over bypass was done with good results. In 1 patient with steal syndrome, RUDI was done with acceptable results. Conclusion: Failing arteriovenous fistula can be salvaged by a variety of techniques provided that it is picked up in time.Keywords: Arteriovenous fistula; arteriovenous graft; fistula salvage
Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP. et al. Editor's Choice - Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018;55(6):757–818.
Almasri J, Alsawas M, Mainou M, Mustafa RA, Wang Z, Woo K, et al. Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis. J Vasc Surg 2016;64(1):236–43.
Al-Jaishi AA, Liu AR, Lok CE, Zhang JC, Moist LM. Complications of the arteriovenous fistula: a systematic review. J Am Soc Nephrol 2017;28(6):1839–50.
Ives CL, Akoh JA, George J, Vaughan-Huxley E, Lawson H. Preoperative vessel mapping and early post-operative surveillance duplex scanning of arteriovenous fistulae. J Vasc Access 2009;10(1):37–42.
Jemcov TK. Morphologic and functional vessels characteristics assessed by ultrasonography for prediction of radiocephalic fistula maturation. J Vasc Access 2013;14(4):356–63.
Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48:S176–247.
Kumbar L. Complications of arteriovenous fistulae: beyond venous stenosis. Adv Chronic Kidney Dis 2012;19(3):195–201.
Gulati S, Sahu KM, Avula S, Sharma RK, Ayyagiri A, Pandey CM. Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail 2003;25(6):967–73.
Li PK, Chow KM. Infectious complications in dialysis-epidemiology and outcomes. Nat Rev Nephrol 2012;8(2):77–88.
Fontsere N, Mestres G, Yugueros X, Lopez T, Yuguero A, Bermudez P, et al. Effect of a postoperative exercise program on arteriovenous fistula maturation: A randomized controlled trial. Hemodial Int 2016;20(2):306–14.
Malovrh M. Non-matured arteriovenous fistulae for haemodialysis: diagnosis, endovascular and surgical treatment. Bosn J Basic Med Sci 2010;10(Suppl 1):S13–7.
Singh P, Robbin ML, Lockhart ME, Allon M. Clinically immature arteriovenous hemodialysis fistulas: effect of US on salvage. Radiology 2008;246(1):299–305.
Oder TF, Teodorescu V, Uribarri J. Effect of exercise on the diameter of arteriovenous fistulae in hemodialysis patients. ASAIO J 2003;49(5):554–5.
Ravani P, Quinn RR, Oliver MJ, Karsanji DJ, James MT, MacRae JM, et al. Pre-emptive correction for haemodialysis arteriovenous access stenosis. Cochrane Database Syst Rev 2016;1:CD010709.
Jimenez-Almonacid P, Gruss-Vergara E, Jimenez-Toscano M, Lasala M, Rueda JA, Portoles J, et al. Surgical treatment of juxtaanastomotic stenosis in radiocephalic fistula. A new proximal radiocephalic anastomosis. Nefrologia 2012;32(4):517–22.
Chen JC, Kamal DM, Jastrzebski J, Taylor DC. Venovenostomy for outflow venous obstruction in patients with upper extremity autogenous hemodialysis arteriovenous access. Ann Vasc Surg 2005;19(5):629–35.
Kian K, Asif A. Cephalic arch stenosis. Semin Dial 2008;21(1):78–82.
Kian K, Unger SW, Mishler R, Schon D, Lenz O, Asif A. Role of surgical intervention for cephalic arch stenosis in the “fistula first” era. Semin Dial 2008;21(1):93–6.
Wang S, Almehmi A, Asif A. Surgical management of cephalic arch occlusive lesions: are there predictors for outcomes? Semin Dial 2013;26(4):E33–41.
Georgiadis GS, Lazarides MK, Panagoutsos SA, Kantartzi KM, Lambidis CD, Staramos DN, et al. Surgical revision of complicated false and true vascular access-related aneurysms. J Vasc Surg 2008;47(6):1284–91.
Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: recognition and management. J Vasc Surg 2008;48(5 Suppl):S55–80.
Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg 2002;35(3):603–10.
Tordoir JH, Bode AS, Peppelenbosch N, van der Sande FM, de Haan MW. Surgical or endovascular repair of thrombosed dialysis vascular access: is there any evidence? J Vasc Surg 2009;50(4):953–6.
Green LD, Lee DS, Kucey DS. A metaanalysis comparing surgical thrombectomy, mechanical thrombectomy, and pharmacomechanical thrombolysis for thrombosed dialysis grafts. J Vasc Surg 2002;36(5):939–45.
Malik J, Tuka V, Kasalova Z, Chytilova E, Slavikova M, Clagett P, et al. Understanding the dialysis access steal syndrome. A review of the etiologies, diagnosis, prevention and treatment strategies. J Vasc Access 2008;9(3):155–66.
Loh TM, Bennett ME, Peden EK. Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation. J Vasc Surg 2016;63(2):441–4.
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