Arteriovenous fistulae vs. arteriovenous grafts: a retrospective review of 1,700 consecutive vascular access cases.

OBJECTIVE: Vascular access (VA) procedures are rapidly becoming the most prevalent surgery in the United States. It is estimated that there will be over 500,000 VA procedures done this year. Previously, surgeons in the US were attempting many more non-autogenous grafts than autogenous fistulae. In recent years, there has been a great push called 'Fistula First' to promote arteriovenous fistulae (AVF) as the first line of treatment vs. nonautogenous grafts. The goal of this investigation is to determine if too many fistulae are now being performed without attention to specific patient profiles. METHODS: A retrospective review of 1700 consecutive cases was performed by one surgeon at one institution between 1997 and 2005. Patients were categorized by demographics, co-morbidities, previous access procedures, access location, and type of graft. Patency was calculated. Kaplan-Meier, Cox regression and the Log Rank Test were used to analyze data. Access endpoints and complications were also documented. RESULTS: The study reviewed 1700 procedures. The median age was 52 (60.2% male) with 58.7% fistulae and 41.3% grafts. Median patency time was 10 months, with no statistically significant difference between access types. There was no significant difference in length of patency when comparing upper arm (70.1%), lower arm (24.5%) and thigh (5.4%). Graft infection rate was 9.5% and fistula infection rate was 0.9% (p<0.001). The overall infection rate was 4.5%, and decreased patency significantly (4 vs. 11 months). Thrombosis occurred in 24.7% of grafts and 9.0% of fistulae. Thrombosed grafts had better salvage rates (8 vs. 4 months, p<0.001). The data showed diabetes, HTN and HIV have no overall impact on patency. CONCLUSIONS: AVF and grafts are both useful in providing VA for patients requiring hemodialysis. Our data shows that grafts are equivalent in long-term patency. Therefore, it is apparent in those patients who are not candidates for an AV fistula; an AV graft for VA should be placed.

Preliminary prospective randomized experience with vascular clips in the creation of arteriovenous fistulae for hemodialysis.

BACKGROUND: A new vascular clipping system (VCS) has been introduced for clinical use. This study was developed to determine whether patency rates and treatment outcomes for anastomoses in hemodialysis access surgery can be improved by the application of this new technology. METHODS: During a 10-month period, 96 consecutive patients requiring autologous fistula, synthetic fistula, or graft revisions for hemodialysis were prospectively randomized into two treatment groups. Anastomoses were constructed with the VCS in 46 patients and with polytetrafluoroethylene (PTFE) suturing in 49 patients. The procedures were performed in an outpatient setting, at a large medical center, by one surgeon. Time to construct the anastomosis, amount of bleeding from the anastomotic site, and primary and secondary graft patencies were analyzed. RESULTS: The mean time to construct anastomoses in autologous and synthetic grafts using VCS clips was significantly shorter than with sutures (autologous 14 versus 22 minutes, P = 0.0001; and new grafts 26 versus 30 minutes, P = 0.04). Blood loss was less in anastomoses done with the VCS clip; however, statistical significance was reached only for autologous fistulas (P = 0.0001). At 2-year follow-up, primary and secondary patencies were similar for both the VCS and suture groups with the exception that a statistically significant improvement was found in secondary patency for autologous fistulas when performed with the VCS. CONCLUSIONS: The VCS clip is easy to use and produces a more rapid anastomosis with less bleeding. Primary and secondary patencies using the VCS clip were equivalent or improved when compared with standard suture. In our experience, no complications have been attributed to the use of the clip technique.

LatisTM catheter: New technology for thrombectomy of vascular access grafts.

PURPOSE: The most common complication of vascular access surgery is thrombosis. This study compared the gold standard Fogarty Thrombectomy Catheter, to the new latis Catheter with an advanced monofilament matrix. METHODS: 30 patients with thrombosed access grafts were randomly assigned to undergo thrombectomy with the Fogarty or latis catheter. An angioscope measured remaining graft thrombi. RESULTS: Twenty-nine of 30 subjects were successfully thrombectomized. No statistical differences in age, gender, race, or extension graft requirements were found. Catheter use in the latis group was: 1 in 14 procedures, and 2 in 1 procedure; Fogarty group: 1 in 10 procedures, 2 in 3 procedures, and 3 in 2 procedures. The average number of catheter passes was: latis 3.06 (1-6 passes) and Fogarty 4.13 (1-9 passes). A trend in favor of the latis catheter was demonstrated; however, statistical significance was not reached (p = 0.067). The overall 6-month primary patency rates were latis (40%) and Fogarty (30%). The estimated patency at the 50th percentile for latis is 120 days and Fogarty 108 days. Statistical significance was not reached with a p-value of the Log-Rank statistic of 0.68 and a p-value of the Wilcoxon statistic of 0.78. CONCLUSIONS: The latis and Fogarty catheters are very similar. However, the latis balloon is more rugged with fewer catheters used and reduced number of passes. A difference in primary patency could not be demonstrated. The angioscope identified significant residual thrombus despite no returning thrombus from the catheter. Consequently, our protocol is modified to include the angioscope.

Challenges of hemodialysis access for high risk patients: Impact of mesenteric vein bioprosthetic graft.

OBJECTIVE: The purpose of this study is to compare in a prospective fashion the performance of a new bioprosthesis, the mesenteric vein bioprosthesis (MVB), in patients who have had multiple failed ePTFE grafts. Performance measures include primary patency rates, assisted-primary patency rates, secondary patency rates, complications, and the number of interventions required to maintain graft patency. STUDY: From October 1999 to February 2002, 276 hemodialysis access grafts were implanted in a multicenter study. Of those grafts, 74 were placed in patients with a prior history of 3 failed prosthetic grafts (mean = 3.5 grafts, range = 3-6 grafts). Fifty-nine grafts were constructed with MVB, and 15 grafts with ePTFE as a concomitant control. Mean follow-up was 11.5 months. In the MVB group, 79.7% were African-Americans, 61% were females, and 23.7% were hypercoagulable. Of the ePTFE group, 86.7% were African-Americans, 46.7% were female, and 13.2% were hypercoagulable. Results : Per Kaplan-Meier curves, the primary patency rate of the MVB group at 12 months was 33% vs the ePTFE group of 18% (p=0.120); the assisted-primary patency rates at 12 months were 45% MVB vs 18% ePTFE (p=0.011). The secondary patency rates at 12 and 24 months for the MVB group were 67% and 59%, respectively, vs 45% and 15% for the ePTFE group (p=0.006). During the follow-up time period, 80% of the ePTFE grafts were abandoned compared to 34% of the MVB group. Infection and thrombosis rates in the MVB group were lower than the ePTFE group. The infection rate for the MVB group requiring intervention was 0.07 events/graft year (gt/y) compared to 0.30 events/gt-y for ePTFE (p=0.04). A thrombosis rate of 0.69 events/gt-y occurred in the MVB group whereas 2.50 events/gt-y presented in the ePTFE group (p<0.01). CONCLUSION: In this study, high-risk patients (defined as those having multiple failed prosthetic grafts for hemodialysis) in whom the MVB conduit for hemoaccess was implanted, showed significant improvement in assisted-primary and secondary patency rates compared to the ePTFE cohort. The MVB group, however, did not have a statistically better primary patency rate compared to the ePTFE group. The MVB patient also had fewer thrombotic and infectious events and an overall reduction in the number of interventions while maintaining a permanent access site. This new bioprosthesis should be the conduit of choice in the complex group of patients as it offers assisted-primary and secondary patency rates similar to those commonly experienced by patients without a history of multiple graft failures.

New graft for low friction tunneling in vascular access surgery.

PURPOSE: Prosthetic accesses of the upper extremity have been in use for more than 25 years. Many different conduits have been employed; investigators have continually searched for a graft with superior properties. METHODS: We describe a prospective randomized study comparing the new Slider Graft (Atrium) with the Hybrid PTFE Graft (Atrium); the latter has been used for a number of years. The Slider Graft is also made of PTFE. For this study, both grafts were 6 mm in diameter and 40 cm in length. The Slider Graft has a low friction polyethylene sheath over its entire length. This sheath expedites the passage of the graft through the tunnel. At one end, the graft and the polyethylene sheath are attached to a metal tip. This tip has male threads, which may be inserted firmly into a Kelly Wyck, Atrium, or any standard non-sheath tunneling system. This alleviates graft separation, turning, and slipping during tunneling. The primary objective of this trial was to determine the safety and efficacy of the Slider Graft as compared to the Hybrid Graft in vascular access surgery. The secondary objective was to evaluate how tunneling effects graft performance. We randomized 60 subjects for this study with two equal arms. During surgery we measured various parameters including ease of tunneling, tunnel bleeding, anastomotic bleeding, graft sweating, and immediate patency. To assess arm edema we measured circumference 7.5 cm and 20 cm above the wrist, prior to surgery and in follow-up visits at 1 week, 1 month, and 3 months. Primary patency was also assessed at these visits and at 6, 9, and 12 months. RESULTS: Our results show tunneling with the Slider Graft is easier to accomplish (p = 0.0001) with reduced tunnel bleeding (p = 0.0047) and anastomotic bleeding (p = 0.042). Further, the Slider Graft virtually eliminated the complication of graft sweating and seroma development (p = 0.0005). This may be due to reduced stretching and graft wetting during insertion. At 180 days the Slider Graft demonstrated improved primary patency, which was statistically significant (p = 0.047). At 360 and 720 days the Slider Graft continued to demonstrate a trend toward improved primary patency (p = 0.160). CONCLUSIONS: This study suggests the Slider Graft has significant advantages when compared to the Hybrid Graft and highlights the importance of tunneling in creating prosthetic accesses.

Bovine artegraft arteriovenous fistulas for hemodialysis in one-hundred patients after "conventional" arteriovenous fistulas failed.

The use of the Bovine artegraft for creation of arteriovenous fistulas in the hemodialysis patients was first carried out in the midsummer of 1971. Since that time, there has been considerable material reported in the use of this substitute as an access for hemodialysis. In this article information gained from an ongoing study of the first 100 patients in chronic hemodialysis who had Bovine artegraft arteriovenous fistulas was reviewed. The indications for operation, the standard technique, the results, the complications, and the future plans for study of the physiology and hemodynamics of this type of fistula are described. The Bovine artegraft, AV fistula can be created successfully in a high percentage of patients, offers ease of needle placement, and effective dialysis with very little complication.

Three year experience with bovine graft arteriovenous (A-V) fistulas in 100 patients.

On the basis of the preceding discussion and information, it is our conclusion that: 1. Bovine graft A-V fistuals can be created successfully in 87% of those patients who have had a failure of conventional fistuals. 2. Bovine graft A-V fistuals provide easy needle placement. 3. Bovine graft A-V fistuals give excellent access for effective hemodialysis. 4. Bovine graft A-V fistuals do not cause excessive bleeding at the puncture site. 5. Bovine graft A-V fistuals can be used immediately.

The utility of the VCS clip for creation of vascular access for hemodialysis: long-term results and intraoperative benefits.

UNLABELLED: The purpose of this study was to compare the effectiveness of the VCS vascular clip approximating system for the creation of hemodialysis access fistulas. 173 new vascular accesses were created, 92 prosthetic grafts and 81 autologous fistulas over a 40-month period. 50 sutured and 42 clipped fistulas comprised the prosthetic graft series, and 33 sutured and 48 clipped cases the autologous series. Risk factors associated with access patency were correlated and the primary patencies compared in the suture versus clipped group. A significant improvement in primary patency was noted for the clipped prosthetic group at all time points studied, with a positive trend also noted for clipped autologous fistulae. CONCLUSIONS: The vascular clipping system (the VCS system) provides both long-term and immediate advantages for vascular access construction. Clips have been used successfully to treat seven consecutive patients with upper extremity arterial steal syndrome without the technical difficulties associated with traditional methods of repair.