Use of bovine carotid artery for buttonhole technique hemodialysis.

PURPOSE: Assess the feasibility of using a bovine carotid artery graft for buttonhole technique hemodialysis in patients who are not candidates for a native fistula. METHODS: Case reports used to demonstrate selection criteria and results for this approach. Criteria include: knowledgeable patient with prior dialysis experience, stable graft in place for 3 months minimum, not a candidate for a native fistula, and able to maintain close follow-up. RESULTS: Both grafts were based on axillary vessels and have been in place for a total of 64 months. They have been used for dialysis via buttonhole for a total of 40 months. There have been three procedures on these patients, post-buttonhole use (.87/year). There have been no infections. CONCLUSIONS: These patients were carefully selected based on desire, support, knowledge/experience and ability. Their success suggests that buttonhole technique for hemodialysis on a synthetic semi-biologic graft can be accomplished with morbidity and longevity similar to any graft using non-buttonhole needle access.

Early use conversion of the HeRO dialysis graft.

Although more challenging to place, the HeRO device (Hemosphere Inc, Eden Prairie, Minn) provides the dialysis access-challenged patient the opportunity to have an upper extremity graft rather than being dependent on a catheter or requiring a lower extremity access. A major difficulty with the HeRO is the need for a concomitant dialysis catheter until the graft matures. This has been associated with a large number of bacteremia episodes. Currently available early-access grafts have patency rates similar to standard polytetrafluoroethylene. We have modified the HeRO insertion technique to combine its attributes with those of an early-use graft. In the five patients presented in this report, we confirm that this new technique can give the patient a graft that is functional ≤72 hours and obviate the need for a concomitant catheter. This results in an infection-free access over the follow-up period.

Early cannulation prosthetic graft (Flixene™) for arteriovenous access.

PURPOSE: Preferred hemodialysis (HD) access is an autologous fistula. Vascular grafts are used in patients with vessels unsuitable to accomplish an arteriovenous fistula (AVF). It is recommended that most current grafts mature in situ for 2-3 weeks before being accessed. Graft complications occur because the structure was not designed for the trauma of repeated cannulation. This study graft has a different structure that enables early use. Its design minimizes weeping through the graft walls and is meant to endure repeated access, thus minimizing the use of HD catheters. The purpose of this study was to show that the Flixene™ graft can be safely placed in patients where fistulas have failed and can be cannulated in 24-72 hr, while maintaining patency rates similar to other polytetrafluoroethylene (PTFE) grafts on the market. Flixene™ configuration should also reduce the incidence of pseudoaneurysms and seromas. METHODS: A prospective two-center study placed 33 grafts in 33 patients; graft efficacy, post-operative complications, and patency were evaluated. Ease of cannulation and dialysis center complications related to early cannulation were documented. Six month follow-up data was analyzed. RESULTS: Successful access was achieved in all 33 patients within 72 hr (29 patients within 24 hr). Overall primary patency at 6 months was 49%; primary-assisted patency at 6 months was 80%. No pseudoaneurysms or seromas were documented at 6 months. Complications were typical of graft access. CONCLUSION: Early cannulation was successful in all patients. Primary and secondary patency rates at 6-months were equivalent to other data reported on PTFE grafts. Flixene™ successfully prevented pseudoaneurysm and seroma formation at 6 months of prospective follow-up. This graft is a better last-resort option for patients who cannot receive a fistula, compared to double-lumen cuffed catheters.

Comparison of clinical assessment with ultrasound flow for hemodialysis access surveillance.

HYPOTHESIS: Organized clinical assessment of hemodialysis access is as useful a surveillance tool as ultrasound flow measurements in preventing access thrombosis. DESIGN: Cohort analysis comparing a dialysis unit evaluated using ultrasound flow measurements with another unit evaluated clinically. SETTING: University-affiliated community program with private and health maintenance organization dialysis units. PATIENTS: One hundred patients in each unit were enrolled. Patients who were unavailable for follow-up or died within the first 30 days of enrollment were excluded from further analysis. INTERVENTION: Angiograms were obtained in the Transonics Doppler ultrasound system (Transonics Systems Inc, Ithaca, New York) cohort if graft flow was less than 600 mL/min, fistula flow was less than 450 mL/min, or flow decreased more than 25%, and in the clinical cohort if there was a change in the access appearance, change in the bruit, or a sharp increase in venous resistance. MAIN OUTCOME MEASURES: Primary and secondary patencies of the hemodialysis access were analyzed for each cohort. Subset analysis was obtained for synthetic grafts and native fistulas. Procedures were assessed for each cohort. RESULTS: The patients in the clinical cohort had similar primary patency (1199 days) as in the Transonics cohort (1162 days) (P = .92). Angiographic procedures were also similar, with 56% of all patients having none. The mean number of procedures was 0.56 per patient in the Transonics cohort and 0.48 in the clinical group (P = .48). CONCLUSION: An organized clinical assessment, using a formal tracking tool, is equal to ultrasound flow measurements as a surveillance method to prevent hemodialysis access thrombosis.