Outcomes of arteriovenous fistula reconstruction in vascular access dysfunction

Abstract

Background: Complications such as stenosis, thrombosis, aneurysmal dilatation, and infection occur in at least one-third of all arteriovenous fistulas (AVFs). Due to these complications, vascular access dysfunction develops in hemodialysis patients.

Objectives: We investigated AVF rescue operations, which we performed for the pathologies causing dysfunctional vascular access, and outcomes of these operations by surgeon-performed preoperative ultrasound (US) in our clinic.

Design: Retrospective Study.

Settings: Bursa Yüksek Ihtisas Training and Research Hospital Cardiovasculary Surgery Department, Turkey.

Patients and methods: 67 patients who were treated in our clinic due to AVF dysfunction between January 2012 and January 2016 were included in the study. Preoperative US evaluation for dysfunctional AVFs was performed by the surgeon conducting the operation. The patients were divided into 5 groups according to the pathologies such as stenosis, thrombosis, aneurysm, high-flow rate, and deep basilic vein.

Main outcome measures: Our goal in all patients with vascular access dysfunction was to maintain the AVF.

Sample size: 67 Patients.

Results: In Group 1 (16 patients) which had stenosis and underwent AVF reconstruction, the 24-month primary patency rate was 81.3%. In Group 2 (9 patients) which had trombosis and underwent AVF reconstruction, the 24-month primary patency rate was 22.2%. In Group 3 (24 patients) which had AVF aneurysm and underwent AVF reconstruction, the 24-month primary patency rate was 70.8%. In Group 4 (10 patients) which had high flow and underwent AVF reconstruction, the 24-month primary patency rate was 90%. In Group 5 (8 patients) which had deep basilic vein and underwent AVF reconstruction, the 24-month primary patency rate was 75%.

Conclusion: Leaving patients with vascular access dysfunction to fate (no intervention) or AVF ligation is always simpler and easier. However, it should not be forgotten that paternity for vascular access are limited in these patients. We think that the primary target is to demonstrate AVF by physical examination and surgeon-performed detailed US and to make it again available for hemodialysis by reconstructing dysfunctional AVF using the most appropriate surgical strategy.

Limitations: Retrospective, small sample size.

Keywords: Arteriovenous fistula; aneurysm; arteriovenous fistula reconstruction; stenosis; ultrasound.

Figure 1

A. Surgical planning with the aid of preoperative US. B. Minimal surgical incisions for AVF reconstruction. C. Creating subcutaneous tunnels for the PTFE graft. D. Completed anastomoses after the PTFE graft being passed under the skin.

Figure 2

A. Preoperative US mapping of AVF stenosis due to repeated dialysis needle insertion attempts. B. Placement of a PTFE interposition graft following excision of the stenotic segment of the AVF after surgical procedure.

Figure 3

A. Surgical exploration of high-flow AVF. B. Banding procedure with the Dacron graft, narrowing of the fistula.

Figure 4

Kaplan-Meier curves; cumulative primary patency rates for twenty four months.