AVF, there is not likely to be sufficient length to reach a non-thrombosed segment of axillary vein. A prosthetic extension to the jugular is another alternative. Adequate central outflow from the jugular would need to be assured by venography before further consideration of either option.14,19

Question 10

Although there is very little data to provide a clear answer to this clinical problem, the best choice and DOQI recommendation is prosthetic interposition. [Q10: C] It preserves a functioning access in someone who has already lost the use of the contralateral upper extremity to venous outflow obstruction.1,20,21

Ligation solves the bleeding problem but sacrifices the access. Removal may subsequently be required, but is not essential at this juncture. Revision with primary closure of the aneurysm is unattractive since the tissues and graft material are friable and usually destroyed by the repetitive puncture. Close observation is doomed to fail with a real risk of bleeding and hemorrhage.

Although prosthetic interposition is the appropriate choice, this option is not without complications. Our own experience identified an increased incidence of infection, and good material to anastomose may require bypass of lengthy segments.22 Recent introduction of the covered stent is an attractive, but expensive and unproven option. Percutaneous access, control of the neck of the pseudoaneurysm, and retention of hemoaccess function are currently offset by limited clinical data, and high expense.13,23

Comment

The initial use of distal sites, and judicious consumption of the available autogenous assets facilitated construction of several different hemoaccess sites during this patient’s 14-year odysseywithhemodialysis.Problemssuchasthesearecommonandrequireforethoughtand ingenuity for successful cumulative function and minimization of major complications.

References

 1. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: Update 2000. Am J Kidney Dis. 2001:37:S137–81.

 2. Stack AG. Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis. 2003;41:310-318.

 3. Khan IH. Co-morbidity: the major challenge for survival and quality of life in end stage renal disease. Nephrol Dial Transplant. 1998;13:S176-79.

 4. Powe NR. Early referral in chronic kidney disease: an enormous opportunity for prevention. Am J Kidney Dis. 2003;41:505-507.

 5. Pisoni RL, Young EW, Dykstra DM, et al. Vascular access use in Europe and the United States: results from the DOPPS. Kidney Int. 2002;61:305-316.

 6. Silva MB, Hobson RW, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation. J Vasc Surg. 1998;27:302-308.

 7. Sidawy AN. The Society for Vascular Surgery: Clinical Practice Guidelines for surgical placement and maintenence of arteriovenous hemodialysis access. J Vasc Surg 2008;48:S2-255.

 8. Miller PE, Tolwani A, Luscy CP, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int. 1999;56:275-280.

 9. Wong V, Ward R, Taylor J, Selvakumar S, How TV, Bakran A. Factors associated with early failure of arteriovenous fistulae for haemodialysis access. Eur J Vasc Endovasc Surg. 1996;12:207-213.

10.Hodges TC, Fillinger MF, Zwolek RM, Walsh DB, Bech F, Cronenwett JL. Longitudinal comparison of dialysis access methods: risk factors for failure. J Vasc Surg. 1997;26:1009-1019.

11.Kalman PG, Pope M, Bhola C, Richardson R, Sniderman KW. A practical approach to vascular access for hemodialysis and predictors of success. J Vasc Surg. 1999;30:727-733.

12.Choi HM, Lal BK, Cerveira JJ, Padberg FT, Hobson RW, Pappas PJ. Durability and cumulative functional patency of transposed and non-transposed arterio-venous fistula. J Vasc Surg. 2003;38(6):1206-1212.

13.Cerveira JJ, Padberg FT, Pappas PJ, Lal BK. Prevention and management of complications fromhemoaccess.In:PearceW,YaoJ,MatsumuraJ,eds.TrendsinVascularSurgery.Chicago, IL: Greenwood Academic; 2004.

14.Currier CBJ, Widder S, Ali A, Kuusisto E, Sidawy A. Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula. Surgery. 1986;100:25-28.

15.Surratt RS, Picus D, Hicks ME, Darcy MD, Kleinhoffer M, Jendrisak M. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. AJR Am J Roentgenol. 1991;156:623-625.

16.Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg. 2003;38:1005-1011.

17.Silva M, Hobson RW, Simonian GT, Haser PB, Jamil Z, Padberg FT, et al. Successful autogenous hemodialysis access placement after prosthetic failure: the impact of non-invasive assessment. Poster presentation at SVS/AAVS 2000, Toronto, CA.

18.Haser PB, Padberg FT Jr. Complex solutions for hemoaccess. In: Matsumura J, Pearce W, and Yao JST, eds. Trends in Vascular Surgery, 2003;Ch 33.

19.Puskas JD, Gertler JP. Internal jugular to axillary vein bypass for subclavian vein thrombosis in the setting of brachial arteriovenous fistula. J Vasc Surg. 1994;19:939-42.

20.Raju S. PTFE grafts for hemodialysis access. Techniques for insertion and management of complications. Ann Surg. 1987;206:666-673.

21.Ryan SV, Calligaro KD, Sharff J, Dougherty MJ. Management of infected prosthetic dialysis arteriovenous grafts. J Vasc Surg. 2004;39:7378.

22.Padberg FT, Lee BC, Curl GR. Hemoaccess site infection. Surg Gynecol Obstet. 1992;174: 103-108.

23.LinPH,JohnsonCK,PulliumJK,etal.TransluminalstentgraftrepairwithWallgraftendoprosthesis in a porcine arteriovenous graft pseudoaneurysm model. J Vasc Surg. 2003;37:175-181.

Miltos K. Lazarides and Vasilios D. Tzilalis

A 65-year-old woman with end-stage renal disease and insulin-dependent diabetes was admitted for access construction in order to start haemodialysis. There was a lack of suitable veins to construct an arteriovenous (AV) fistula, and the patient underwent placement of a 6-mm polytetrafluoroethylene (PTFE) AV bridge graft between the brachial artery and the axillary vein in the left arm.

Question 1

Which of the following is the order of preference for placement of a permanent angioaccess in new patients requiring chronic haemodialysis?

A.  (1) A brachio-cephalic AV fistula. (2) A wrist radial-cephalic AV fistula. (3) An AV PTFE bridge graft or a transposed brachial-basilic AV fistula. (4) A cuffed, tunnelled central venous catheter

B.  (1) A wrist radial-cephalic AV fistula. (2) A brachio-cephalic AV fistula. (3) An AV PTFE bridge graft or a transposed brachial-basilic AV fistula

C.  (1) A wrist radial-cephalic AV fistula. (2) A transposed brachial-basilic AV fistula. (3) A brachio-cephalic AV fistula. (4) An AV PTFE bridge graft

Question 2

Which of the following statements represent advantages of the autologous AV fistulas over AV grafts?

A.  Excellent long-term patency once established B.  Lower complication rate

M.K. Lazarides ( )

Department of Vascular Surgery, Demokritos University Hospital, Alexandroupolis, Greece