Graft Inclusion Technique: A New Flow Reduction Procedure for High Flow Arteriovenous Fistulae

Abstract

Objective: Flow reduction is required to preserve vascular access in cases with high flow access (HFA). We report a new flow reduction procedure, the graft inclusion technique (GIT). Methods: The GIT procedure developed by us involves the intraluminal placement and suturing of a 4-mm polytetrafluoroethylene graft to the anastomosis and outflow tract to plicate the enlarged anastomosis and maintain lower flow volumes. Flow reduction for HFA was retrospectively assessed in a series of 25 patients (age 65±12 years; 17 males and 8 females) to evaluate flow volume and patency rate, wherein 10 patients underwent conventional methods of flow reduction and 15 underwent GIT. Results: Compared with preprocedure values, mean flow volume (MFV) was significantly lower after the procedure with both the conventional methods (1,817 vs. 586 ml/min; P<0.05) and the GIT (2,262 vs. 890 ml/min; P<0.05). An increase in MFV occurred during follow-up after conventional flow reduction (586 vs. 1,036 ml/min), while GIT could maintain lower MFV (890 vs. 791 ml/min), suggesting that GIT can significantly lower MFV levels (2,262 vs. 791 ml/min; P<0.05) and maintain these lower MFV levels during follow-up. Secondary patency rate for the GIT was 100% at 1 year and 83% at 3 years. Conclusion: The GIT may be used as an access-preserving, reliable, long-term, and stable flow-reducing procedure that does not require flow adjustment during surgery.

Keywords: flow reduction procedure; hemodialysis access-induced distal ischemia; high flow vascular access; high output heart failure; venous hypertension.

Fig. 1 Graft inclusion technique procedure. (A) The diameter of the anastomosis site is reduced to that of the graft by suturing a 4-mm polytetrafluoroethylene graft under direct vision. (B) The other end of the graft, cut at a length of approximately 4 cm, is sutured to the outflow tract. (C) The surplus vascular wall is trimmed and closed using a running suture. (D) The graft is completely included in the autologous vascular wall.

Fig. 2 Changes in flow volume in all patients. (A) Conventional method and (B) graft inclusion technique.

Fig. 3 Postoperative angiography for graft inclusion technique (GIT). (A) Postoperative angiography in a patient who had undergone GIT. The diameter of the outflow tract vein is usually sufficiently wide and stenosis is unlikely to occur at the outflow anastomosis site, thereby contributing to longer patency. (B) Percutaneous transluminal angioplasty in the central vein was performed in patients with venous hypertension.