Frank T. Padberg and Robert W. Zickler

A 42-year-old type 1 diabetic of normal weight has recently progressed to chronic renal disease. Insulin-dependent diabetes mellitus (DM) has been managed by the same primary care physician for the preceding 12 years; glucose control has never been a problem in this cooperative and well-educated individual. The renal failure was initially managed with appropriate adjustments to diet and medications; the presumptive diagnosis is diabetic nephropathy. Recent laboratory tests demonstrate a creatinine of 4.1, a blood urea nitrogen of 94, a potassium of 4.8, mild proteinuria, and a creatinine clearance of 20 mL/min.

Question 1

At this juncture the physician’s most appropriate course of action is:

A.  Refer the individual to a surgeon for hemoaccess.

B.  Refer the individual to a nephrologist to refine diagnosis and initiate specialty care. It is not time to initiate dialysis.

C.  Refer the individual to a nephrologist who will refine diagnosis, and determine if there is a reversible cause for the renal insufficiency.

D.  Refer the individual to a nephrologist who will evaluate the etiology of the renal insufficiency and determine if there is a reversible cause. If not, a surgeon skilled in the construction of durable hemoaccess should be consulted.

E.  Refer the individual to a nephrologist to commence dialysis with a central venous catheter.

F.T. Padberg ( )

Division of Vascular Surgery, Department of Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA

Question 2

A nephrology work-up finds no reversible cause and the patient’s immune status precludes any further consideration of transplantation. The patient is referred for construction of a hemoaccess. The most appropriate action is to perform a clinical vascular examination with specific attention to:

A.  The pedal pulses and examination of the foot; extensive arterial occlusive disease is common in diabetic patients and infection would complicate any hemoaccess procedure.

B.  Theradialpulsesandsuperficialvenousanatomy.Booktheoperatingroomandproceed to construct an access in the upper extremity, guided by your clinical examination.

C.  Theradialpulsesandsuperficialvenousanatomysupplementedbyaduplexultrasound (DU) study. Book the operating room and proceed to construct an access in the upper extremity guided by these findings.

D.  Immediate hemoaccess placement. Simultaneous placement of an arteriovenous fistula (AVF) and a central venous catheter.

Question 3

Preoperative DU examination should include all except one of the following:

A.  Both upper extremities.

B.  Size and location of the arteries. C.  Location of the brachial bifurcation.

D.  Assessment of the axillary and subclavian veins. E.  At least one lower extremity.

F.  Size and location of the superficial veins.

G.  Evaluation of the superficial veins for evidence of prior scarring.

The patient is right hand dominant. Non-invasive examination demonstrated the findings given in the caption to Fig. 41.1.

Right: Cephalic (diameter 3.3 mm) and basilic (diameter 3.5 mm) veins course through both the forearm and upper arm to their junctions with the axillary and brachial veins respectively;however,bothsuperficialforearmveinsdemonstratepost-thromboticchanges in the forearm. The brachial artery (diameter 4.2 mm) bifurcates into a radial (diameter 2.8 mm) and ulnar (diameter 2.7 mm) artery 3 cm below the antecubital crease; the palmar arches are intact. The deep venous structures are normal from the forearm veins through visualization of the axillary and subclavian veins.

Left: The basilic vein is post-thrombotic and thickened in the forearm; it has a normal 3.5-mm diameter lumen just below the elbow continuing into its junction with the brachial vein at mid-humerus. The cephalic vein (diameter 3.5 mm) has a normal luminal surface, extends to the wrist, is superficial, communicates with the proximal basilic at the

Fig. 41.1  Duplex ultrasound: The patient is right hand dominant. Non-invasive examination demonstrated the following findings. Top diagram: left arm bottom diagram: right arm red=arterial antomy blue=superficial veins Dotted blue=diseased vein as described in text

antecubital junction, and remains patent into its junction with the axillary vein. The brachial artery (diameter 4.2 mm) bifurcates into a radial (diameter 2.8 mm) and ulnar (diameter 2.7 mm) artery at mid-humerus; the palmar arches are intact. The deep venous structures are normal from the forearm veins through visualization of the axillary and subclavian veins.

Question 4

Which procedure would be the best option for this individual?

A.  Left brachial to basilic transposition AVF in the arm. B.  Right radial to basilic transposition AVF in the forearm.

C.  Left brachial to median antecubital vein forearm loop graft (PTFE).

D.  Left internal jugular (IJ) tunneled, cuffed dual lumen hemodialysis catheter. E.  Left radial to cephalic AVF.

Question 5

Which of the following best describes when this new hemoaccess is considered mature enough to begin puncture for hemodialysis?

A.  The wound is securely healed, the sutures have been removed, and there is a palpable thrill.

B.  The wound is securely healed, the sutures have been removed, and there is a palpable thrill. At 2 weeks, a duplex examination demonstrates unobstructed flow, but the walls of the conduit appear to be relatively thin.

C.  The wound is securely healed, the sutures have been removed, and there is a palpable thrill. At8 weeks,a duplexexaminationdemonstratedthatthere wasunobstructedflow and the walls of the conduit have thickened measurably.

D.  The wound is securely healed, the sutures have been removed, and there is a palpable thrill. At 6 weeks, a duplex examination demonstrates an equal volume of flow through both the fistula vein and a large branch vein at the site of the thrill.

E.  Two weeks.

Your initial hemoaccess has functioned well for 6.4 years, but the hemodialysis staff has noted increasing difficulty obtaining adequate flows for the external machine circuit; arterial pressures were low at 70 mm Hg and venous pressures elevated to 350 mm Hg. You are asked to consider revision or a new hemoaccess.

A new duplex examination demonstrates progressive stenosis of the distal radial artery, and multiple sites of localized thrombosis extending into the upper arm cephalic vein. You determine that there is no role for angioplasty of the lengthy arterial stenosis or the multiple venous lesions. With the exception of the appropriate postoperative changes, the remainder of the examination is unchanged from that described in Fig. 41.1.

Question 6

Which is the best option to maintain hemodialysis?

A.  Right radial to basilic transposition AVF in the forearm. B.  Right forearm loop graft (PTFE).

C.  Left forearm loop graft (PTFE).

D.  Left radial (antecubital) to basilic transposition AVF in the arm. E.  Left IJ tunneled, cuffed dual lumen hemodialysis catheter.

A new hemoaccess is constructed and an excellent thrill achieved. During initial maturation, hemodialysisis continued via the originalleft armhemoaccess. Fortunately, the original left hemoaccess provides sufficient flow for adequate interval hemodialysis, but 6 weeks later has spontaneously thrombosed. Dialysis using the new hemoaccess is successful and the hemoaccess functions well for thrice weekly puncture.

Twoyearslateryouareagaincontactedtoevaluatethisindividual.Oneyearpreviously, an uneventful coronary bypass was performed. Subsequently, following an episode of syncope,andtachyarrhythmia,apermanentdefibrillatorwasinstalledontheleftanteriorchest wall 2 months ago (Fig. 41.2).

Fig. 41.2  The chest X-ray was taken at the time of the referral for arm edema

The patient is complaining of an obviously swollen left arm.

Question 7

What is wrong?

A.  The patient’s heart failure has worsened from a combination of a fixed heart rate and the increased output demanded for the hemoaccess.

B.  Edema is a result of lymphatic disturbance from defibrillator implantation.

C.  The patient is hypercoagulable and has thrombosis of the superior vena cava (SVC). D.  Unilateral swelling results from continuously increasing flow in the hemoaccess and

enlargement of the arterial anastomosis.

E.  The transvenous electrodes have induced a stenosis or obstruction of the left subclavian vein.

Question 8

The best treatment for this condition is?

A.  Begin strong diuresis to counter the right heart failure.

B.  Place the arm in a sling and elevate it to reduce the existing edema from the operation. The patient is reassured that edema following pacemaker insertion of these devices is usually self-limited and will soon resolve.

C.  The defibrillator is removed and replaced in the right subclavian vein.

D.  A fistulagram/venogram is performed. This will determine the etiology of the edema and may offer an opportunity for interventional therapy.

E.  A hypercoagulable work-up is obtained.

All of the interventions aimed at reducing the left arm edema are unsuccessful, and the patient is discharged home. After multiple attempts, the dialysis staff reluctantly admit they are no longer able to reliably cannulate the left arm AVF. You are again asked to consider revision or a new hemoaccess.

A new DU is obtained. The appropriate postoperative findings are noted; otherwise, the relevant arm anatomy is unchanged from the initial survey as shown in Fig. 41.1.

Question 9

The optimal hemoaccess for this individual now is:

A.  Right forearm loop graft (PTFE). Ligation of left hemoaccess.

B.  Left IJ tunneled, cuffed dual lumen hemodialysis catheter. Ligation of left hemoaccess.

C.  Right IJ tunneled, cuffed dual lumen hemodialysis catheter. Ligation of left hemoaccess. D.  Left femoral to femoral loop graft (PTFE). Ligation of left hemoaccess.

E.  Left femoral tunneled, cuffed dual lumen hemodialysis catheter. F.  Right brachial-cephalic transposition.

The left arm symptoms resolve, and the new access functions well for 2.6 additional years. However, dilation begins to appear in two sites most commonly used for the tri-weekly puncture for hemodialysis. Duplex examination of the larger discerns the presence of a large pseudoaneurysm with a 0.6-mm neck communicating with the lumen of hemoaccess. The individual reports several recent episodes of prolonged difficulty achieving hemostasis after removal of the access needles. During duplex interrogation, a thrombotic plug is dislodged. Pulsatile bleeding ensues, which is controlled with 30–45 min of direct compression.

Question 10

The best treatment option at this time is:

A.  Ligation of the hemoaccess.

B.  Revision by primary closure of the pseudoaneurysm.

C.  Revision with placement of an interposition, prosthetic segment. D.  Removal of the hemoaccess.

E.  Continued, but close, observation of the patient with treatment initiated if the bleeding recurs.

After loss of the above hemoaccess, a new autogenous AVF was available for construction in the right arm, which remained functional until the patient’s demise 3 years later.