A modified approach of proximalization of arterial inflow technique for hand ischemia in patients with matured basilic and cephalic veins.

OBJECTIVE: Proximalization of arteriovenous inflow (PAI) is an established technique for treating patients with access-induced hand ischemia. However, a prosthetic graft, used as arterial inflow, could minimize the benefits of a purely native fistula. In this study, a new PAI technique is reported, which avoids the use of prosthetic grafts in patients with matured basilic and cephalic veins. PATIENTS AND METHODS: Eight patients (seven men, one woman; mean age 62 (45-82) years old) with grade III/IV critical dialysis access-related ischemia (DARI) and with a pre-existing Gracz fistula underwent an operation using modified PAI. The basilic and cephalic veins were preoperatively matured. During the operation, the former arteriovenous anastomosis was closed and the basilic vein was used as arterial inflow. RESULTS: All procedures were technically successful. All patients but one could be discharged with a warm, neurologically improved extremity with a significant reduction in pain. After a mean follow-up of 43.5 (0-52) months, there were no recurrent steal symptoms and all necrotic hand lesions healed. Two patients died during the follow-up, but with well-functioning fistulae. One fistula failed during follow-up and one further fistula was ligated because of chronic neurological damage, which was not improved after the PAI procedure. Four AVFs are still available for hemodialysis. CONCLUSIONS: The modification of the PAI technique with a basilic vein as presented here showed similar results to the original PAI procedure. This new procedure does not require prosthetic grafts as in the original PAI technique or a central venous catheter and leads to the enlargement of the puncture site as a result of the superficialization of the basilic vein. Therefore, it is believed that this new technique could be a good option for those patients with matured cephalic and basilic veins who suffer from severe access-related ischemia.

Primary vascular access in diabetic patients: an audit.

BACKGROUND: The increasing proportion of diabetic patients in the haemodialysis population, mainly elderly patients with diabetes mellitus type 2, is a challenge to nephrologists and vascular surgeons. The aim of this study was to assess different strategies in an effort to improve the commonly disappointing results of arteriovenous (a-v) fistula surgery in this group of patients. STRATEGIES: Besides the availability of a suitable vein, special attention was paid to the quality of the artery, based on clinical and recently available ultrasonographic parameters. In the case of peripheral arterial narrowing and/or calcification, the elbow region was the preferred location for creation of the first a-v fistula, taking into consideration the reduced life expectancy of the majority of diabetic patients. Furthermore, a clinical surveillance programme was established to treat the failing, not the failed fistula. To this end, elective revisions were performed prior to the onset of thrombosis to correct stenoses, aneurysms, and other signs of fistula dysfunction. Absolute priority was given to the use of native vessels. RESULTS: During the period January 1993 to December 1995, 347 primary Brescia-Cimino fistulae were performed out a total of 799 access procedures. No graft material was used in these first operations. The patients were followed up until 31 July 1998. Of these 347 patients, 269 were non-diabetic and 78 were diabetic. Two hundred and two of all 347 first a-v fistulae were created in the forearm/wrist region, 182 in non-diabetic patients and 20 in diabetic patients, whereas the elbow region was used in 145 patients, 87 in non-diabetic and 58 in diabetic patients. Based on the carefully planned choice of location of the first operation and the strategy of elective revisions, virtually identical results for non-diabetic and diabetic patients could be obtained with regard to revision and patency rates. Some differences were observed with regard to the types of revision. CONCLUSION: A strategy is presented that helps to reduce the vascular access problems in diabetic and elderly patients.

Recent developments in vascular access for hemodialysis.

Vascular access surgery is a permanent challenge for the vascular surgeon and is a very dynamic, inter-disciplinary field in modern medicine. High technical skill, extreme care and continuity to gain as much experience as possible are required. Priority should be given to the patients' native vessels. Nevertheless, grafts do have a place provided special attention is paid to the restricted indications. Close co-operation of the vascular surgeon, the nephrologist and the radiologist is essential. The nephrologist is responsible for access surveillance and for early detection of fistula dysfunction. Dialysis related parameters should be observed routinely; clinical examination and if necessary ultrasonographic and angiographic technique will give further information. Recently introduced methods such as permanent central venous catheters and an increasing variety of interventional procedures must be critically evaluated in the future.

[Surgical removal of a cerebral arterial aneurysm complicating renal failure; anaesthesiological and post-operative problems (author's transl)]. / Operation eines hirnarteriellen Aneurysmas bei terminaler Niereninsuffizienz: Anästhesiologische und intensiv-medizinische Massnahmen

A case of cerebral arterial aneurysm associated with renal failure is reported which was treated by surgery. The anaesthesiological and post-operative problems are discussed. Surgery of the aneurysm is urgently indicated in these cases on account of the increased risk of subarachnoid haemorrhage due to heparinization during haemodialysis. Pre-operative replacement of haemodialysis by peritoneal dialysis is advisable to facilitate the treatment of cerebral oedema, maintain the electrolyte and water balance and ensure adequate post-operative enteral and parenteral feeding. The choice of anaesthetic technique, the use of controlled hypotension, the treatment of hypertensive crises, laboratory tests and the post-operative care of these cases are discussed. Experience has shown that from the anaesthesiological point of view there is no contra-indication to neurosurgery or vascular surgery in cases of renal failure provided adequate precautions are taken.