Reverse-loop upper arm arteriovenous graft for chronic hemodialysis

Abstract

Options for an upper arm arteriovenous graft (AVG) commonly include the placement of a straight prosthetic graft connecting the brachial artery to the axillary vein. However, such configuration leads to underutilization of the upper arm veins, resulting in the loss of venous capital in the upper arm for future secondary fistula creation. In this retrospective analysis, we evaluated seven patients who had upper-arm AVGs created in a reverse-loop configuration. The prosthetic graft was created by connecting the brachial artery close to the cubital fossa and tunneled subcutaneously in a looped fashion distally thereby connecting the basilic or deep brachial vein just above the elbow. Endpoints were interventions, thrombosis, and loss of access at the last examination. The brachial vein was used in two patients and the basilic vein in the other five. The median duration of follow-up with 100% patency of the AVGs was 10.0 (range, 3.0-25.0) months. Patients were able to achieve a target hemodialysis dose with a (K(urea) x t(d))/V(urea) value of 1.4 (range, 1.2-1.5). The median flow rates achieved were 205.0 (range, 203.3-236.7) and 266.7 (range, 203.3-276.7) ml/minute at the first and 3-month dialysis sessions, respectively. The median dialysis venous pressures were 128.0 (range, 108.3-178.0) and 131.0 (range, 116.7-148.7) mmHg at the first and third month after operation, respectively. The median peak systolic velocity ratios of artery-graft and vein-graft junctions were 2.1 (range, 1.4-2.4) and 3.0 (range, 2.3-3.8) cm/second, respectively. In conclusion, this is a logical approach for patients who have exhausted their forearm vessels for AVG creation. In addition, it also provides a platform for future creation of a secondary fistula in the upper arm.