A review of patients with renal disease undergoing vascular access surgery: is gray-scale ultrasound enough?

BACKGROUND: An adequate fistula or graft is essential to long-term survival and quality of life for patients with end-stage renal disease (ESRD) who are receiving hemodialysis because of its lower complication rates, lower costs, and prolonged patency. Use of duplex ultrasound for preoperative planning is currently recommended by the Kidney Disease Outcomes Quality Initiative for patients with ESRD with prior fistulas or grafts, central lines, pacemakers, and prior chest or arm surgery. The preoperative evaluation consisted of gray-scale ultrasound and physical examination in all patients with ESRD in this study. The current study determined the baseline data, including the type of vascular access, functional patency of access, associated morbidity, and preoperative demographics and comorbidities, including prior dialysis access. The primary objective was to determine the frequency of revision surgery, to identify the potential cases that may indicate the need for better assessments (eg, duplex ultrasound), and to improve fistula and graft success rates. MATERIALS AND METHODS: A retrospective chart review of patients with ESRD who underwent native fistula or graft access creation in a 13-month time period from 2010 to 2011 was completed. Seventy-six surgical procedures were performed on 53 subjects. Included variables were age, race, gender, smoking status, body mass index, stage of chronic kidney disease at referral, previous central lines/pacemakers, fistulas, or grafts. Comorbidities identified included diabetes mellitus (DM), hypertension (HTN), and coronary artery disease (CAD). The types of access, location, maturation, infection, failure, or revision were noted. Continuous variables are shown in frequencies and mean. Categoric data were compared using chi-square analysis. RESULTS: During the 13-month study period, 76 surgical procedures were performed in 53 patients, with 39.6% of patients undergoing multiple surgical procedures. The majority of patients were male (98%) and white (58.5%), with a history of HTN (96.2%) and DM (64.2%). The mean age was 68 years, with most patients presenting in stage 5 chronic kidney disease (92.5%). Some 67.9% of patients had prior central lines or pacemakers; of those, 56.6% had previous fistulas or grafts. Negative significance was determined between the comorbidities DM/HTN/CAD alone or grouped as a cohort and multiple surgeries. Positive significance was found between multiple surgical procedures and those with prior access/pacemaker/central line (chi-square [1, N = 53] = exact P = .04). CONCLUSIONS: Patients with ESRD undergoing access creation presenting with prior central lines, pacemakers, or arm surgery (fistulas or grafts) were more likely to undergo multiple surgeries to obtain a functional graft or fistula for hemodialysis use than those patients with ESRD without prior central lines, pacemakers, or arm surgery (fistulas or grafts). Color duplex ultrasound should be considered as a standard for preoperative assessment in an effort to improve fistula or graft success rates.

Irreversible sequela in an arterial venous fistula with steal syndrome: a case study.

Arteriovenous fistulas may be susceptible to steal syndrome from a variety of conditions. Steal syndrome is defined as arterial insufficiency distal to the arteriovenous fistula. The causality of the insufficiency may include arterial disease proximal or distal to the fistula, markedly high blood flow volume after creation, or undetected collateral flow. Prior arterial disease may expose insufficient profusion to the distal extremity after fistula creation. High blood flow volume immediately after fistula creation may perhaps cause steal syndrome symptoms, but this often resolves with fistula maturation. Undetected collateral flow, or side branches, from target vessels receive increased blood volume after fistula creation and expand, thereby stealing blood flow from the hand. This particular condition can potentially cause ischemic changes distal to the fistula with potentially irreversible sequela if not recognized in a timely manner. A sixty- one year old male, sent with chest pain to the emergency room from his dialysis center, was found to have steal syndrome with an accompanying motor deficit. The diagnosis of steal syndrome is based on physical examination, patient history, and confirmation testing such as doppler ultrasound, digital pressures or arteriogram. A thorough preoperative workup and careful postoperative monitoring can minimize steal syndrome and prevent permanent impairment.