A Large Single Center Experience Of Management Of Aneurysmal Degeneration Of Arteriovenous Fistulas For Hemodialysis
Sonia Sharma, MD, Donna Bednarski, CNP, Yevgeniy Rits, MD.
Detroit Medical Center, Detroit, MI, USA.
OBJECTIVES: Aneurysmal degeneration (AD) is a known complication of autogenous arteriovenous fistulas (AVF) for hemodialysis. Surgical treatment options of AD to maintain autogenous AVF patency include plication, excision with primary anastomosis, interposition graft or stent placement. The aim was to assess outcomes of surgical modalities in the management of AD of autogenous AVFs at a single major dialysis access institution.
METHODS: A retrospective study was conducted to identify patients with AD of AVFs from January 2016 to December 2018. Indications for intervention were size, skin changes, and thrombosis. Interventions included plication, excision with primary anastomosis, interposition graft and stent placement. Outcomes were followed for 2 years.
RESULTS: 1677 access surgeries were performed, of which 73 patients underwent surgical correction of AD. 69.9% of patients were male, with mean age of 58.6 years and 82.2% were African American. All patients had hypertension, 30.1% diabetes, 34.2% coronary artery disease, 27.4% stroke, 6.8% peripheral arterial disease and 38.4%% congestive heart failure. 63% of patients had a brachiocephalic(BCF), 31.5% radiocephalic(RCF) and 5.5% basilic vein transposition(BVT) fistulae. 56 patients underwent plication, 7 excision and primary anastomosis, 9 interposition graft, and 1 stent placement. Mean time from AVF creation date to index intervention was 2650.8 days(d) for RCF, 1773.3d for BCF, and 1420d for BVT (p<0.003). Primary patency rates for plication were 70.3% at 3 months, 35% at 1 year, 17% at 2 years and were 87.5% at 3 months, 62.5% at 1 year, and 50% at 2 years for all other combined interventions. Release date of the fistula for dialysis use was 30.3d for plication, 27.5d for excision and anastomosis, 3.9d for interposition graft patients, and 7d for stented patients (P<0.001). Only 28.2% of patients required post operative catheter placement, demonstrating continued use of autogenous AVF. Mean time from creation to failure date of AVF was 3285d for plication, compared to 2577d for the other interventions combined (p= 0.52). 13 plication patients had an additional 19 plication procedures in the follow-up period.
CONCLUSIONS: Aneurysmal repair of fistulas with plication, and other surgical modalities are a viable option to help maintain autogenous hemodialysis access. There is no difference in patency rates between surgical modalities. Multiple plications are a useful intervention to help maintain longevity of the AVF preserving future access sites.
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