Simultaneous Cephalic Arch Reconstruction, Aneurysmorrhaphy, And Revision Of Inflow For Arteriovenous Fistula Salvage
Tarundeep Singh, MD, Travis J. Vowels, MD, Eric K. Peden, MD.
Division of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA.
OBJECTIVES: Cephalic arch and central venous stenosis, aneurysmal dilatation, and inflow disease are common to arteriovenous fistulas (AVF) and provide a significant challenge in the hemodialysis access community. We report our experience with extensive revision by simultaneously addressing 2 or more of these issues for AVF salvage. METHODS: We retrospectively reviewed all patients undergoing extensive AVF revision over a 5-year period at our institution. We evaluated technical success and patency rates and rates of post-operative complications.
RESULTS: Sixty-eight patients underwent extensive revision of their AVFs during this period. Average age was 54 years and 60% were male. Most were brachiocephalic AVFs (51%), followed by radiocephalic (18%), and brachiobasilic (12%). Thirty patients (44%) required interventions to maintain their dialysis access prior to undergoing extensive revision. Average time from creation to revision was 68 months. Indications included aneurysmal dilatation (96%), high flow (54%), cephalic arch stenosis (34%), dialysis associated steal syndrome (DASS) (10%), or a combination (76%). Mean access flow was 2100 ml/min prior to revision and 1300 ml/min after. Extensive revision involved aneurysmorrhaphy in 60 patients (88%), tunneled dialysis catheter placement in 44 (65%), revision using distal inflow in 25 (37%), cephalic arch reconstruction or turndown in 14 (20%), angioplasty of outflow veins in 11 (16%), and proximalization of inflow in 5 (7%). Extensive revision was technically successful in 67 patients (98%). Postoperative complications included hematoma in 3 (4%) patients and DASS in 2 (3%). Primary patency at 6, 12, 18, and 24 months was 93%, 91%, 87%, and 79%, respectively. Primary, primary-assisted, and secondary patency rates were 74%, 78%, and 91%, respectively.
CONCLUSIONS: The lifespan of arteriovenous fistulas can be extended significantly, thereby postponing the need for abandonment and creation of new forms of hemodialysis access. Extensive surgical revision is a safe and effective means for arteriovenous fistula salvage.
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