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Early experience with a novel “hybrid” graft used for hemodialysis access
Javier E. Anaya-Ayala, MD, Matthew K. Adams, BS, Charudatta S. Bavare, MD, Jean Bismuth, MD, Alan B. Lumsden, MD, Eric K. Peden, MD, Mark G. Davies, MD, PhD, MBA, Joseph J. Naoum, MD.
Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
Background: Achieving functional dialysis access in patients with few or hard to access open deep veins is an ongoing challenge in the present day. The development of new technologies may provide an alternative to conventional approaches and maximize the use of the extremity’s venous real-estate while reducing the operative insult to these generally fragile patients.
Methods: We describe our initial experience with the hybrid vascular graft (W. L. Gore and Associates, Flagstaff, Ariz.) in 23 patients. The hybrid graft allows for a stented and sutureless distal anastomosis which can be performed using endovascular access. Selection criteria included: no acceptable peripheral alternative access site, previous graft anastomosis or a stent in the venous target at the level of the axilla, failed brachial-basilic upper arm transposition arteriovenous fistula or a target vein < 0.3 cm within the axilla. Patient demographics and early patency were evaluated.
Results: Technical success was accomplished in all 23 cases (100%), 7 required a Viabahn (W. L. Gore and Associates, Flagstaff, Ariz.) stent-graft extension and two additional patients percutaneous angioplasty (PTA) to improve venous outflow at the axillary and/or subclavian veins at the time of surgery. Nineteen patients are currently using the hybrid graft for hemodialysis while two recently had the procedure and are not yet using their grafts. 2 patients developed dialysis associated steal syndrome (DASS) requiring plication of the inflow graft segment and one of them also required stenting of the brachial artery to improve inflow. During the follow up period two patients died of comorbidities nonrelated to the access procedure while having a functioning graft
Conclusion: This early experience shows that the hybrid graft concept appears to be a safe and technically effective alternative for patients with a disadvantaged anatomy in whom dialysis access is needed. Long-term data will be required to validate it as a preferential option in patients with limited venous real-estate.
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