Creation of a Transposed Mature Arteriovenous Fistula Autograft: A Novel Approach to Treating Steal Syndrome.

BACKGROUND: Autogenous arteriovenous fistula (AVF) creation is the gold standard of hemodialysis access. However, autologous upper extremity AVFs continue to present significant clinical challenges including failure to mature and steal syndrome. We describe treating a patient with dialysis-associated steal syndrome (DASS) by ligating and then transposing a well-developed, mature upper arm cephalic vein AVF into the contralateral arm. METHODS: Our patient is a 76-year-old female with end-stage renal disease (ESRD) secondary to glomerulonephritis, who had a left arm brachiocephalic AVF created in 2007. She developed DASS in 2013, presenting with hand pain and ulcerations on her fingertips. A right brachial-cephalic AVF was created with plans of ligating the left AVF once mature. The right arm AVF did not mature so we created an arteriovenous graft (AVG) in the right arm utilizing the mature left arm cephalic vein as an autograft. RESULTS: The autograft was transposed and implanted in the right upper arm. The translocated AVF worked for 4 years and was eventually ligated due to right hand ischemia secondary to progression of small vessel peripheral arterial disease. CONCLUSIONS: Transposition of autogenous vein grafts using a mature AVF is a viable option for dialysis access in ESRD patients. We report successful utilization of this novel access option in the treatment of a patient with DASS. The mature autograft retains the natural matrix and endothelial lining and thus may potentially prove to offer improved patency and reduced infection rate compared to other available AVG options.

Hemodialysis Access in the Elderly: Outcomes among Patients Older than Seventy.

BACKGROUND: Arteriovenous fistulae (AVF) are the preferred access for hemodialysis, however, there continues to be limited data guiding the surgical management of primary dialysis access creation in elderly end-stage renal disease patients. METHODS: This is an 8-year retrospective institutional study evaluating the operative and clinical characteristics of patients 70 years or above who underwent primary, first-ever, AVF or arteriovenous graft (AVG) creation. RESULTS: There was no overall significant difference in AVF and AVG primary (P = 0.127) and secondary (P = 0.870) patency. AVG had higher graft loss secondary to infection (P = 0.0002) and thrombosis (P = 0.0213). Survival was less than 50% at 2 years for AVF and AVG patients. An equal number of AVF and AVG patients who died had functional access at the time of death (P = 1.0000) with more AVG patients using their graft (initiating dialysis) before death (P = 0.0118). CONCLUSIONS: Elderly patient patency rates for AVF and AVG are satisfactory and support surgical access creation; however, overall 2-year survival is low. An equal number of AVF and AVG patients died with functioning surgical access, however, more AVG patients initiated dialysis and successfully used their access. Accordingly, special consideration needs to be given with regard to estimated timing until dialysis and predicted patient longevity. Delaying access creation until dialysis is needed and proceeding with AVG creation appears to be justified.

Current outcomes and indications for cryopreserved vein allografts in hemodialysis access surgery.

INTRODUCTION: Cryopreserved vein allografts (cadaveric vein) have emerged as an option for arteriovenous graft reconstruction; however, indications for their use in hemodialysis access remains to be clearly defined. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with a history of infection, recurrent access failure and advanced age. METHODS: This is a 10-year retrospective study. Primary outcomes were (1) to identify characteristics specific to this patient population and (2) to better define indications for use of cadaveric vein in hemodialysis access creation. RESULTS: Indications for creation of CVGs included patient history of either active or recent infection (41.5%), recurrent access failure (43.4%) or surgeon preference secondary to patients' advanced age (9.4%). Observed primary patency rates were 84.9% (30 days), 22.6% (1 year) and 16.0% (2 years). Secondary patency was 93.4% (30 days), 66.0% (1 year) and 52.8% (2 years). Patient death was the highest cause of graft abandonment (52.9%) followed by thrombosis (19.1%), infection (11.7%) and rupture (11.7%). CVG patency at the time of patient death was 83.7%. CONCLUSIONS: The rates of both primary and secondary patency in CVGs are highly comparable to the reported patency rates of polytetrafluoroethylene (PTFE) grafts and allow for lifelong maintenance of dialysis access. Our observed outcome suggests that CVGs should be considered for patients needing vascular access in the presence of infection. CVGs may likewise be viable alternatives to PTFE grafts in the elderly and patients with limited access options.

An Outcomes Comparison of Native Arteriovenous Fistulae, Polytetrafluorethylene Grafts, and Cryopreserved Vein Allografts.

BACKGROUND: Despite almost 2 decades of experience with cadaveric vein, there remains a paucity of available data regarding the role of cadaveric vein in hemodialysis, specifically with regard to outcomes and patency. Observations from our own experience have suggested that cadaveric vein grafts (CVGs) provide good outcomes, particularly in patients with recurrent access failure. Accordingly, this study aims to comparatively examine patency, access-related outcomes, and survival in patients undergoing placement of arteriovenous fistulae (AVF), polytetrafluorethylene (PTFE) grafts, and CVGs. METHODS: This is a single institution 11-year retrospective case series evaluating the outcomes of 210 patients who underwent creation of AVF, PTFE grafts, and CVGs for hemodialysis access. Patients in the AVF (n = 70) and arteriovenous graft (AVG; n = 70) groups were matched to the CVG (n = 70) group by age, gender, and access location. Postoperative end points for all groups included primary and assisted patency, cause of access abandonment, and survival. RESULTS: Patients were matched for age (P = 0.8707), gender (P = 0.6958), and access location and no significant differences existed between groups. AVF showed superior primary patency at 30 days, 1 year (64.3%, P < 0.0001) and 2 years (54.3%, P = 0.0091) in comparison to both AVG and CVG. AVG had reduced patency at 30 days (84.3%, P = 0.0009), 1 year (50.0%, P < 0.0001), and 2 years (32.9%, P = 0.0001) in comparison to AVF and CVG groups. Overall, AVF had the highest patency at all-time points followed, respectively by CVG and AVG. No significant difference existed between AVF and CVG groups with regard to secondary patency at 30 days (98.6% vs. 97.1%, P = 1.0000), 1 year (81.4% vs. 78.6%, P = 0.6749), and 2 years (68.6% vs. 51.4%, P = 0.0573). AVG patients had decreased survival (years) after access creation in comparison to AVF and CVG groups (P = 0.0003). CONCLUSIONS: Our findings lend further support to the use of cadaveric vein for hemodialysis access surgery. As demonstrated through this comparative study, CVGs are capable of providing favorable results with regard to patency, access longevity, and patient survival. These current outcomes indicate that cadaveric vein is a sustainable alternative to PTFE for hemodialysis access surgery and should be accordingly considered for difficult access patients.